Member
3663
Billing provider
7090
DOS
2025-04-06
DB status
paid
Total charge
$527.08
Allowed
$263.10
Paid
$188.96
Member resp.
$74.14
Claim lines (1)
| # | Procedure | Mod | Units | Charge | Allowed | Paid |
|---|---|---|---|---|---|---|
| 1 | S99213 | 1 | $527.08 | $263.10 | $188.96 |
Diagnoses: K21.9*E66.9
Agent chain trace
intake_validator5 tool call(s)provider_lookupprovider 7090: NPI 1245683242 (individual, 207R00000X) active128mseligibility_lookupmember 3663: enrolled in plan 8 (self_spouse) on 2025-04-06167mscode_lookupCPT S99213: Synthetic Office Visit Established Patient Low-Moderate Comp (active)129mscode_lookupICD-10-CM K21.9: Gastro-esophageal reflux disease without esophagitis (active)243mscode_lookupICD-10-CM E66.9: Obesity unspecified (active)141ms
eligibility1 tool call(s)eligibility_lookupmember 3663: enrolled in plan 8 (self_spouse) on 2025-04-06179ms
coding_edits2 tool call(s)mue_checkno MUE rule for S99213 on 2025-04-06150msncci_checkno NCCI PTP rule for S99213+S99213 on 2025-04-06139ms
pricing1 tool call(s)fee_schedule_lookupno fee schedule line for S99213 on 2025-04-06152ms
Review gate decisions (1)
pend_to_humanpayby
disposition · conf 0.502026-04-26 01:49:49confidence_below_thresholddollar_within_caprules_verified_by_agent_tool_callsno_risk_flags
Explanation of Benefits
Status: paidClaim
85021
Member
3663
Provider
7090
Date(s) of Service
2025-04-06
| Service | Charged | Allowed | Not covered | Plan paid | You owe |
|---|---|---|---|---|---|
| S99213 | $527.08 | $263.10 | $263.98 | $188.96 | $74.14 |
| Totals | $527.08 | $263.10 | $263.98 | $188.96 | $74.14 |
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 01:49:49 per policy 1.