Professional claim · CMS-1500 · EDI 837P
CLM-2026-005821
Summit Medical Group, Internal Medicine. Service 2026-01-26 at office (POS 11). Received 2026-03-10.
Approved
Billed
$567.00
3 lines
Allowed
$351.54
contract rate applied
Plan pays
$311.54
approved
Member owes
$40.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Barbara Jackson
- Member ID
- UHC-50069-87
- Date of birth
- 1999-07-19
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-424697
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4956
- Coverage period
- 2025-12-01 to 2026-05-04
- Deductible
- $814.51 of $2,500.0033%
- Out-of-pocket maximum
- $2,502.00 of $10,000.0025%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3585197395
- Network
- In network
- Rendering NPI
- 7165710451
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $396.00 | $245.52 | $40.00 | $205.52 | Paid |
| 2 | 93000 | Electrocardiogram with interpretation | 25 | 1 | 1,2 | $113.00 | $70.06 | $0.00 | $70.06 | Paid |
| 3 | 80053 | Comprehensive metabolic panel | — | 1 | 2 | $58.00 | $35.96 | $0.00 | $35.96 | Paid |
| Totals | $567.00 | $351.54 | $40.00 | $311.54 | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. I10 Essential (primary) hypertension
Claim header
- Patient account
- PA-481467
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-018611 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-26: CHOICE-PLUS-PPO (PPO), effective 2025-12-01, terms 2026-05-04. | |
| Timely filing | Pass | Received 43 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. |
Evaluated 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Summit Medical Group2026-01-26 12:50
Patient seen for type 2 diabetes mellitus with hyperglycemia.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$567.00
Plan discount
$215.46
contracted rate
Plan paid
$311.54
You may owe
$40.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
No other claims.
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.