CLM-2026-001328
Summit Medical Group, Internal Medicine. Service 2025-10-16 to 2025-10-17 at inpatient hospital (POS 21). Received 2026-01-26.
Member
Resolved through the identity graph
- Member
- James Richardson
- Member ID
- UHC-80635-16
- Date of birth
- 1943-05-17
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-425174
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-1931
- Coverage period
- 2024-11-01 to present
- Deductible
- $1.67 of $1,000.000%
- Out-of-pocket maximum
- $694.53 of $2,000.0035%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3585197395
- Network
- In network
- Rendering NPI
- 2859122733
- Location
- Miami, FL · TIN 90-8787389
- Authorisation / referral
- none / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $255.00 | $140.25 | — | — | DeniedCO29 |
| Totals | $255.00 | $140.25 | — | — | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
- 3. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-332363
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2025-10-16 to 2025-10-19
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-003977 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2025-10-16: SELECT-EPO (EPO), effective 2024-11-01. | |
| Timely filing | Fail | CO29 | Received 101 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Summit Medical Group (3585197395). | |
| 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 Medical Group2025-10-17 13:21
Patient seen for copd, unspecified.
- SystemSystem: Claims system2026-01-26 06:17
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-01-26 13:40
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-332363.pdf3 pages
Itemised statement totalling $255.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 101 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-000641 | 2026-09-28 | Valley Rehabilitation Center | $285.00 | Approved |
| CLM-2026-030186 | 2026-08-20 | Summit Regional Medical Center | $1,903.00 | Approved |
| CLM-2026-022326 | 2026-03-10 | Meadow Heart Institute | $423.00 | 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
Received after the timely-filing limit.