CLM-2026-002360
Summit Family Practice, Family Medicine. Service 2026-09-22 at office (POS 11). Received 2026-10-11.
Member
Resolved through the identity graph
- Member
- Virginia Smith
- Member ID
- UHC-62024-73
- Date of birth
- 2001-07-22
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-405399
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-1354
- Coverage period
- 2025-03-01 to 2026-03-17
- Deductible
- $187.10 of $1,000.0019%
- Out-of-pocket maximum
- $824.40 of $4,000.0021%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 3071022859
- Network
- In network
- Rendering NPI
- 2756596757
- Location
- Minneapolis, MN · TIN 67-3208363
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $307.00 | $190.34 | — | — | DeniedCO27 |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $226.00 | $140.12 | — | — | DeniedCO27 |
| Totals | $533.00 | $330.46 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- 3. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-357023
- 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-004480 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-22 is after coverage terminated on 2026-03-17. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 19 days after service (limit 90). | |
| 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 Family Practice (3071022859). | |
| 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 Family Practice2026-09-22 10:00
Patient seen for encounter for general adult medical examination without abnormal findings.
- SystemSystem: Claims system2026-10-11 04:30
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-10-11 16:23
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-09-22 is after coverage terminated on 2026-03-17.
Other claims for this member
Same resolved identity
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
Service after coverage termination.