837P Professional Claim
CLM-2026-0481 Ready
Service date Jun 02, 2026 · Riverside Main · Place of service 11
Claim Information
Patient
Robert Tran · MRN 02981
Insurance
Blue Shield CA · PPO Gold 500
Rendering Provider
Dr. Anjali Patel
Member ID
XJZ884201773
Encounter
Service Date
Jun 02, 2026
Diagnosis Codes (ICD-10)
| Seq | ICD-10 | Description |
|---|---|---|
| 1 | I50.9 | Heart failure, unspecified |
| 2 | E11.9 | Type 2 diabetes mellitus without complications |
| 3 | I10 | Essential (primary) hypertension |
Service Lines (CPT)
| # | CPT | Description | DX | Units | Charge | Allowed | Auth |
|---|---|---|---|---|---|---|---|
| 1 | 99214 | Office visit, established, moderate | 1,3 | 1 | $178.00 | $142.40 | — |
| 2 | 93306 | Echocardiography, transthoracic, complete | 1 | 1 | $612.00 | $489.60 | |
| 3 | 85025 | Complete blood count (CBC) w/ differential | 2 | 1 | $38.00 | $24.70 | — |
| 4 | 83036 | Hemoglobin A1c | 2 | 1 | $54.00 | $35.10 | — |
| Totals | $882.00 | $691.80 | |||||
Financial Summary
Total Charges$882.00
Allowed Amount$691.80
Insurance Paid$553.44
Adjustments$190.20
Patient Responsibility$138.36
Balance Due$138.36
Status History
Draft created
Jun 03 · 09:14 · by Coder L. Marsh
Coded & reviewed
Jun 03 · 11:02 · by Coder L. Marsh
Ready to submit
Jun 04 · 08:40 · by Biller K. Adler
Awaiting submission
Prior auth pending on line 2
Contract Reference
Blue Shield CA · PPO Gold 500 fee schedule
99214$142.40 allowed
93306$489.60 allowed
85025$24.70 allowed