CLM-2026-005679
Summit Medical Group, Internal Medicine. Service 2026-01-28 to 2026-01-30 at inpatient hospital (POS 21). Received 2026-03-02.
Member
Resolved through the identity graph
- Member
- Lisa Foster
- Member ID
- UHC-72634-68
- Date of birth
- 1995-08-24
- Identity
- Verified6 records, confidence 0.92
- Claim record
- CLMCLM-406079
- Relationship
- Child, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2861
- Coverage period
- 2024-06-01 to present
- Deductible
- $446.42 of $500.0089%
- Out-of-pocket maximum
- $327.30 of $1,000.0033%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3585197395
- Network
- In network
- Rendering NPI
- 5325614993
- 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 | $226.00 | $124.30 | $60.65 | $63.65 | Paid |
| Totals | $226.00 | $124.30 | $60.65 | $63.65 | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- Patient account
- PA-616119
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-01-28 to 2026-01-29
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-016880 (verified, link confidence 0.92). | |
| Eligibility | Pass | Active on 2026-01-28: NULL (PPO), effective 2024-06-01. | |
| Timely filing | Pass | Received 31 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 | 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 Group2026-01-30 18:21
Established patient presents with copd, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-616119.pdf4 pages
Itemised statement totalling $226.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012971 | 2026-06-03 | Unity Clinical Laboratories | $67.00 | Needs review |
| CLM-2026-031316 | 2026-04-29 | Sunrise Family Practice | $301.00 | Approved |
| CLM-2026-014015 | 2026-02-02 | Lakeside Bone and Joint Center | $51,201.00 | Needs review |
| CLM-2026-002584 | 2026-03-02 | Canyon Diagnostic Imaging | $4,241.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.