Member
9912
Billing provider
4497
DOS
2025-06-28
DB status
paid
Total charge
$275.99
Allowed
$142.82
Paid
$108.43
Member resp.
$34.39
Claim lines (1)
| # | Procedure | Mod | Units | Charge | Allowed | Paid |
|---|---|---|---|---|---|---|
| 1 | S99213 | 1 | $275.99 | $142.82 | $108.43 |
Diagnoses: E66.9*
Agent chain trace
intake_validator4 tool call(s)provider_lookupprovider 4497: NPI 1871518530 (individual, 207RC0200X) active182mseligibility_lookupmember 9912: enrolled in plan 23 (self) on 2025-06-28153mscode_lookupCPT S99213: Synthetic Office Visit Established Patient Low-Moderate Comp (active)179mscode_lookupICD-10-CM E66.9: Obesity unspecified (active)162ms
eligibility1 tool call(s)eligibility_lookupmember 9912: enrolled in plan 23 (self) on 2025-06-28117ms
coding_edits2 tool call(s)mue_checkno MUE rule for S99213 on 2025-06-28144msncci_checkno NCCI PTP rule for S99213+S99213 on 2025-06-28164ms
pricing1 tool call(s)fee_schedule_lookupno fee schedule line for S99213 on 2025-06-28320ms
Review gate decisions (1)
pend_to_humanpayby
disposition · conf 0.602026-04-26 01:50:18confidence_below_thresholddollar_within_caprules_verified_by_agent_tool_callsno_risk_flags
Explanation of Benefits
Status: paidClaim
291904
Member
9912
Provider
4497
Date(s) of Service
2025-06-28
| Service | Charged | Allowed | Not covered | Plan paid | You owe |
|---|---|---|---|---|---|
| S99213 | $275.99 | $142.82 | $133.17 | $108.43 | $34.39 |
| Totals | $275.99 | $142.82 | $133.17 | $108.43 | $34.39 |
This EOB reflects amounts on the claim record. For chain-proposed figures (which may differ when the chain used synthetic-rate fallback), see the agent trace above — pricing/v0.2.0 emits a
synthetic_rate_used risk_flag when fee schedule data was missing.pend_to_human on 2026-04-26 01:50:18 per policy 1.