Member
3930
Billing provider
8891
DOS
2024-11-11
DB status
paid
Total charge
$622.18
Allowed
$263.10
Paid
$225.05
Member resp.
$38.05
Claim lines (1)
| # | Procedure | Mod | Units | Charge | Allowed | Paid |
|---|---|---|---|---|---|---|
| 1 | S99213 | 1 | $622.18 | $263.10 | $225.05 |
Diagnoses: J06.9*
Agent chain trace
intake_validator4 tool call(s)provider_lookupprovider 8891: NPI 1235625849 (organization, 207RH0003X) active191mseligibility_lookupmember 3930: enrolled in plan 3 (self_spouse) on 2024-11-11170mscode_lookupCPT S99213: Synthetic Office Visit Established Patient Low-Moderate Comp (active)205mscode_lookupICD-10-CM J06.9: Acute upper respiratory infection unspecified (active)320ms
eligibility1 tool call(s)eligibility_lookupmember 3930: enrolled in plan 3 (self_spouse) on 2024-11-11170ms
coding_edits2 tool call(s)mue_checkno MUE rule for S99213 on 2024-11-11176msncci_checkno NCCI PTP rule for S99213+S99213 on 2024-11-11166ms
pricing1 tool call(s)fee_schedule_lookupS99213 on 2024-11-11: preferred $233.03 (Commercial HMO 2024); 2 match(es) total208ms
Review gate decisions (1)
pend_to_humanpayby
disposition · conf 0.952026-04-26 00:07:22confidence_below_thresholddollar_within_caprules_verified_by_agent_tool_callsno_risk_flags
Explanation of Benefits
Status: paidClaim
91168
Member
3930
Provider
8891
Date(s) of Service
2024-11-11
| Service | Charged | Allowed | Not covered | Plan paid | You owe |
|---|---|---|---|---|---|
| S99213 | $622.18 | $263.10 | $359.08 | $225.05 | $38.05 |
| Totals | $622.18 | $263.10 | $359.08 | $225.05 | $38.05 |
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 00:07:22 per policy 1.