CLM-2026-005462
Summit Family Practice, Family Medicine. Service 2026-01-30 at office (POS 11). Received 2026-02-17.
Member
Resolved through the identity graph
- Member
- Rachel Maldonado
- Member ID
- UHC-51088-81
- Date of birth
- 1940-03-05
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-403432
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5554
- Coverage period
- 2021-10-01 to 2026-07-16
- Deductible
- $473.86 of $3,500.0014%
- Out-of-pocket maximum
- $3,074.04 of $7,000.0044%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 9865039744
- Network
- In network
- Rendering NPI
- 4531363180
- Location
- Scottsdale, AZ · TIN 65-7813683
- 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 | 36415 | Venipuncture | — | 1 | 1 | $15.00 | $9.30 | — | — | Review |
| 2 | 99395 | Preventive visit, 18-39 years | 25 | 1 | 2 | $301.00 | $186.62 | — | — | Review |
| Totals | $316.00 | $195.92 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-622174
- 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-009565 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-30: - (PPO), effective 2021-10-01, terms 2026-07-16. | |
| Timely filing | Pass | Received 18 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 (9865039744). | |
| 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: “Patient seen for hyperlipidemia, unspecified. Note dictated; signature pending.”. 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 Family Practice2026-01-30 16:08
Patient seen for hyperlipidemia, unspecified. Note dictated; signature pending.
- SystemSystem: Claims system2026-02-17 05:06
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Patient seen for hyperlipidemia, unspecified. Note dictated; signature pending.”.
Other claims for this member
Same resolved identity
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.