CLM-2026-003830
Summit Medical Group, Internal Medicine. Service 2026-07-12 at office (POS 11). Received 2026-07-22.
Member
Resolved through the identity graph
- Member
- Tyler Meyer
- Member ID
- UHC-06884-65
- Date of birth
- 1964-04-20
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-428439
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-3800
- Coverage period
- 2025-09-01 to present
- Deductible
- $305.47 of $1,000.0031%
- Out-of-pocket maximum
- $151.60 of $4,000.004%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3585197395
- Network
- In network
- Rendering NPI
- 9120452930
- Location
- Miami, FL · TIN 90-8787389
- 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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $75.00 | $46.50 | — | — | Review |
| Totals | $75.00 | $46.50 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-496057
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-019673 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-12: SELECT-EPO (EPO), effective 2025-09-01. | |
| Timely filing | Pass | Received 10 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 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 | Review | CO16 | Documentation incomplete: “Established patient presents with chronic kidney disease, stage 3 unspecified; symptoms re”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Summit Medical Group2026-07-12 17:14
Established patient presents with chronic kidney disease, stage 3 unspecified; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-07-22 01:49
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-07-22 15:28
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 engineReview2026-10-22 12:44Completeness: Documentation incomplete: “Established patient presents with chronic kidney disease, stage 3 unspecified; symptoms re”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-026400 | 2026-02-07 | Canyon Cardiovascular Associates | $343.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.