Claims workbench/CLM-2026-000714
Professional claim · CMS-1500 · Paper

CLM-2026-000714

Summit Family Practice, Family Medicine. Service 2025-12-22 at office (POS 11). Received 2026-01-27.

Approved
Billed
$20.00
1 line
Allowed
$12.40
contract rate applied
Plan pays
$0.00
approved
Member owes
$12.40
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Therresa Roggers
Member ID
UHC-93439-83
Date of birth
1966-02-03
Identity
Verified2 records, confidence 0.99
Claim record
CLMCLM-429478
Relationship
Self, Mesa, AZ

Coverage and accumulators

Found by member ID

Plan
- PPO group GRP-1814
Coverage period
2023-05-01 to present
Deductible
$1,213.65 of $3,500.0035%
Out-of-pocket maximum
$4,759.46 of $14,000.0034%
Copays
office $25.00, specialist $60.00, emergency $350.00
Physical therapy visits
10 of 20 used

Provider

Billing and rendering

Billing provider
Summit Family Practice
Family Medicine · taxonomy 207Q00000X
NPI
3071022859
Network
In network
Rendering NPI
5337238260
Location
Minneapolis, MN · TIN 67-3208363
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
136415Venipuncture—11$20.00$12.40$12.40$0.00Paid
Totals$20.00$12.40$12.40$0.00
Diagnoses (ICD-10-CM)
  • 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
  • 2. J06.9 Acute upper respiratory infection, unspecified
  • 3. E78.5 Hyperlipidemia, unspecified
Claim header
Patient account
PA-141128
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 0 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-008100 (verified, link confidence 0.99).
EligibilityPassActive on 2025-12-22: - (PPO), effective 2023-05-01.
Timely filingPassReceived 36 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Summit Family Practice (3071022859).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Summit Family Practice2025-12-22 10:19

    Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Explanation of benefits

What the member will see

Amount billed
$20.00
Plan discount
$7.60
contracted rate
Plan paid
$0.00
You may owe
$12.40
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-22 12:44
    Clean claim.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

Clean claim: the rules engine approved it, so no AI review was needed.

Examiner decision

Approved by Claims rules engine; an examiner may still override

Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queueMember identity