CLM-2026-000366
Summit Endocrine Associates, Endocrinology. Service 2026-01-21 at office (POS 11). Received 2026-02-04.
Member
Resolved through the identity graph
- Member
- Dylan Cole
- Member ID
- UHC-93588-47
- Date of birth
- 2004-07-01
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-427850
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-8895
- Coverage period
- 2022-06-01 to present
- Deductible
- $616.32 of $1,500.0041%
- Out-of-pocket maximum
- $2,908.48 of $6,000.0048%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Endocrine AssociatesEndocrinology · taxonomy 207RE0101X
- NPI
- 3880544135
- Network
- In network
- Rendering NPI
- 4680001433
- Location
- Dallas, TX · TIN 38-9625016
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 83036 | Hemoglobin A1c | — | 1 | 1 | $64.00 | $39.68 | — | — | DeniedCO18 |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $292.00 | $181.04 | — | — | DeniedCO18 |
| 3 | 95251 | Continuous glucose monitoring, analysis | — | 1 | 1 | $214.00 | $132.68 | — | — | DeniedCO18 |
| Totals | $570.00 | $353.40 | — | — | ||||||
- 1. E05.90 Thyrotoxicosis, unspecifiedprincipal
- Patient account
- PA-786756
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-007113 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-21: MEDICARE-ADV-A (MA), effective 2022-06-01. | |
| Timely filing | Pass | Received 14 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-000365: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Summit Endocrine Associates (3880544135). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Summit Endocrine Associates2026-01-21 13:28
Established patient presents with thyrotoxicosis, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-02-04 05:11
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-000365: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-003213 | 2026-02-04 | Pinecrest Regional Medical Center | $1,078.00 | Approved |
| CLM-2026-000365 | 2026-01-21 | Summit Endocrine Associates | $570.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Exact duplicate of an earlier submission.