Member
3928
Billing provider
9217
DOS
2025-03-23
DB status
paid
Total charge
$586.51
Allowed
$263.10
Paid
$211.40
Member resp.
$51.70
Claim lines (1)
| # | Procedure | Mod | Units | Charge | Allowed | Paid |
|---|---|---|---|---|---|---|
| 1 | S99213 | 1 | $586.51 | $263.10 | $211.40 |
Diagnoses: Z34.90*
Agent chain trace
intake_validator4 tool call(s)provider_lookupprovider 9217: NPI 1104485770 (individual, 390200000X) active187mseligibility_lookupmember 3928: enrolled in plan 10 (self) on 2025-03-23141mscode_lookupCPT S99213: Synthetic Office Visit Established Patient Low-Moderate Comp (active)134mscode_lookupICD-10-CM Z34.90: Encounter for supervision of normal pregnancy unspecified un (active)234ms
eligibility1 tool call(s)eligibility_lookupmember 3928: enrolled in plan 10 (self) on 2025-03-23157ms
coding_edits2 tool call(s)mue_checkno MUE rule for S99213 on 2025-03-23171msncci_checkno NCCI PTP rule for S99213+S99213 on 2025-03-23141ms
pricing1 tool call(s)fee_schedule_lookupno fee schedule line for S99213 on 2025-03-23247ms
Review gate decisions (1)
pend_to_humanpayby
disposition · conf 0.502026-04-26 01:51:45confidence_below_thresholddollar_within_caprules_verified_by_agent_tool_callsno_risk_flags
Explanation of Benefits
Status: paidClaim
91106
Member
3928
Provider
9217
Date(s) of Service
2025-03-23
| Service | Charged | Allowed | Not covered | Plan paid | You owe |
|---|---|---|---|---|---|
| S99213 | $586.51 | $263.10 | $323.41 | $211.40 | $51.70 |
| Totals | $586.51 | $263.10 | $323.41 | $211.40 | $51.70 |
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 01:51:45 per policy 1.