Member
1
Billing provider
8655
DOS
2022-06-07
DB status
paid
Total charge
$1392.36
Allowed
$661.37
Paid
$525.25
Member resp.
$136.12
Claim lines (2)
| # | Procedure | Mod | Units | Charge | Allowed | Paid |
|---|---|---|---|---|---|---|
| 1 | S99213 | 1 | $467.25 | $233.03 | $152.91 | |
| 2 | S93000 | 1 | $925.11 | $428.34 | $372.34 |
Diagnoses: I10*K21.9
Agent chain trace
intake_validator18 tool call(s)provider_lookupprovider 8655: NPI 1538680343 (individual, 207RI0200X) active184mseligibility_lookupmember 1: enrolled in plan 4 (self_spouse) on 2022-06-07130mscode_lookupCPT S99213: Synthetic Office Visit Established Patient Low-Moderate Comp (NOT active on DOS)243mscode_lookupCPT S93000: Synthetic Electrocardiogram Routine with 12 Leads (NOT active on DOS)107mscode_lookupICD-10-CM I10: Essential (primary) hypertension (NOT active on DOS)174mscode_lookupICD-10-CM K21.9: Gastro-esophageal reflux disease without esophagitis (NOT active on DOS)174msprovider_lookupprovider 8655: NPI 1538680343 (individual, 207RI0200X) active206mseligibility_lookupmember 1: enrolled in plan 4 (self_spouse) on 2022-06-07122mscode_lookupCPT S99213: Synthetic Office Visit Established Patient Low-Moderate Comp (NOT active on DOS)119mscode_lookupCPT S93000: Synthetic Electrocardiogram Routine with 12 Leads (NOT active on DOS)171mscode_lookupICD-10-CM I10: Essential (primary) hypertension (NOT active on DOS)177mscode_lookupICD-10-CM K21.9: Gastro-esophageal reflux disease without esophagitis (NOT active on DOS)162msprovider_lookupprovider 8655: NPI 1538680343 (individual, 207RI0200X) active244mseligibility_lookupmember 1: enrolled in plan 4 (self_spouse) on 2022-06-07230mscode_lookupCPT S99213: Synthetic Office Visit Established Patient Low-Moderate Comp (NOT active on DOS)175mscode_lookupCPT S93000: Synthetic Electrocardiogram Routine with 12 Leads (NOT active on DOS)252mscode_lookupICD-10-CM I10: Essential (primary) hypertension (NOT active on DOS)194mscode_lookupICD-10-CM K21.9: Gastro-esophageal reflux disease without esophagitis (NOT active on DOS)222ms
coding_edits8 tool call(s)ncci_checkno NCCI PTP rule for S99213+S93000 on 2022-06-07233msmue_checkno MUE rule for S99213 on 2022-06-07166msmue_checkno MUE rule for S93000 on 2022-06-07246msncci_checkno NCCI PTP rule for S93000+S99213 on 2022-06-07182msncci_checkno NCCI PTP rule for S99213+S93000 on 2022-06-07167msmue_checkno MUE rule for S99213 on 2022-06-07187msmue_checkno MUE rule for S93000 on 2022-06-07158msncci_checkno NCCI PTP rule for S93000+S99213 on 2022-06-07140ms
Review gate decisions (7)
pend_to_humanpendby
coding_edits · conf 0.852026-04-25 04:08:23confidence_below_thresholddollar_within_caprules_agreeno_risk_flags
pend_to_humanpendby
coding_edits · conf 0.852026-04-25 04:09:21confidence_below_thresholddollar_within_caprules_agreeno_risk_flags
auto_commitpendby
coding_edits · conf 0.852026-04-25 04:09:22confidence_meets_thresholddollar_within_caprules_agreeno_risk_flags
pend_to_humanpendby
coding_edits · conf 0.852026-04-25 05:31:52confidence_below_thresholddollar_within_caprules_agreeno_risk_flags
auto_commitpendby
coding_edits · conf 0.852026-04-25 05:31:52confidence_meets_thresholddollar_within_caprules_agreeno_risk_flags
pend_to_humanpayby
coding_edits · conf 0.952026-04-25 14:14:11confidence_meets_thresholddollar_within_caprules_consensus_required_but_not_evaluatedno_risk_flags
auto_commitpayby
coding_edits · conf 0.952026-04-25 14:33:49confidence_meets_thresholddollar_within_caprules_verified_by_agent_tool_callsno_risk_flags
Explanation of Benefits
Status: paidClaim
3
Member
1
Provider
8655
Date(s) of Service
2022-06-07
| Service | Charged | Allowed | Not covered | Plan paid | You owe |
|---|---|---|---|---|---|
| S99213 | $467.25 | $233.03 | $234.22 | $152.91 | $80.12 |
| S93000 | $925.11 | $428.34 | $496.77 | $372.34 | $56.00 |
| Totals | $1392.36 | $661.37 | $730.99 | $525.25 | $136.12 |
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.auto_commit on 2026-04-25 14:33:49 per policy 21.