Member
2649
Billing provider
12498
DOS
2025-06-02
DB status
paid
Total charge
$603.32
Allowed
$263.10
Paid
$217.37
Member resp.
$45.73
Claim lines (1)
| # | Procedure | Mod | Units | Charge | Allowed | Paid |
|---|---|---|---|---|---|---|
| 1 | S99213 | 1 | $603.32 | $263.10 | $217.37 |
Diagnoses: J45.909*
Agent chain trace
intake_validator4 tool call(s)provider_lookupprovider 12498: NPI 1093759391 (individual, 207R00000X) active196mseligibility_lookupmember 2649: enrolled in plan 8 (self_spouse) on 2025-06-02125mscode_lookupCPT S99213: Synthetic Office Visit Established Patient Low-Moderate Comp (active)171mscode_lookupICD-10-CM J45.909: Unspecified asthma uncomplicated (active)236ms
eligibility1 tool call(s)eligibility_lookupmember 2649: enrolled in plan 8 (self_spouse) on 2025-06-02200ms
coding_edits2 tool call(s)mue_checkno MUE rule for S99213 on 2025-06-02188msncci_checkno NCCI PTP rule for S99213+S99213 on 2025-06-02158ms
pricing1 tool call(s)fee_schedule_lookupno fee schedule line for S99213 on 2025-06-02174ms
Review gate decisions (1)
pend_to_humanpayby
disposition · conf 0.502026-04-26 01:47:38confidence_below_thresholddollar_within_caprules_verified_by_agent_tool_callsno_risk_flags
Explanation of Benefits
Status: paidClaim
62101
Member
2649
Provider
12498
Date(s) of Service
2025-06-02
| Service | Charged | Allowed | Not covered | Plan paid | You owe |
|---|---|---|---|---|---|
| S99213 | $603.32 | $263.10 | $340.22 | $217.37 | $45.73 |
| Totals | $603.32 | $263.10 | $340.22 | $217.37 | $45.73 |
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 01:47:38 per policy 1.