CLM-2026-002397
Summit Family Practice, Family Medicine. Service 2026-02-28 at office (POS 11). Received 2026-04-06.
Member
Resolved through the identity graph
- Member
- Mason Garrett
- Member ID
- UHC-88787-58
- Date of birth
- 2005-06-06
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-421727
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-2573
- Coverage period
- 2023-01-01 to present
- Deductible
- $489.96 of $2,500.0020%
- Out-of-pocket maximum
- $1,648.00 of $7,500.0022%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 3071022859
- Network
- In network
- Rendering NPI
- 8627371254
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $249.00 | $154.38 | — | — | DeniedCO18 |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 2 | $159.00 | $98.58 | — | — | DeniedCO18 |
| 3 | 36415 | Venipuncture | — | 1 | 1,2 | $22.00 | $13.64 | — | — | DeniedCO18 |
| Totals | $430.00 | $266.60 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-512786
- 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-007987 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-28: OPTIONS-PPO (PPO), effective 2023-01-01. | |
| Timely filing | Pass | Received 37 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-002396: 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 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 Practice2026-02-28 12:03
Established patient presents with acute upper respiratory infection, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-04-06 01:29
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-2026-002396: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002396 | 2026-02-28 | Summit Family Practice | $430.00 | Approved |
| CLM-2026-026352 | 2026-01-09 | Unity Community Hospital | $1,740.00 | 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.