Professional claim · CMS-1500 · EDI 837P
CLM-2026-007551
Summit Medical Group, Internal Medicine. Service 2026-01-28 at office (POS 11). Received 2026-02-02.
Billed
$300.00
2 lines
Allowed
$186.00
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Lawrence Gutierrez
- Member ID
- none on golden record
- Date of birth
- 1960-06-19
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-425343
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- SELECT-EPO EPO group GRP-3372
- Coverage period
- 2022-08-01 to 2026-01-22
- Deductible
- $4.47 of $1,500.000%
- Out-of-pocket maximum
- $169.35 of $4,500.004%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3585197395
- Network
- In network
- Rendering NPI
- 4662501780
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $215.00 | $133.30 | — | — | DeniedCO27 |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $85.00 | $52.70 | — | — | DeniedCO27 |
| Totals | $300.00 | $186.00 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
Claim header
- Patient account
- PA-969563
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-002315; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Fail | CO27 | Date of service 2026-01-28 is after coverage terminated on 2026-01-22. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 5 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 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Summit Medical Group2026-01-28 15:44
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-02-02 05:37
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Member identity: Member record is in open steward case CASE-002315; payment withheld until the identity is confirmed. Eligibility: Date of service 2026-01-28 is after coverage terminated on 2026-01-22.
Other claims for this member
Same resolved identity
No other claims.
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Denied 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
DeniedCO27scenario: Coverage terminated
Service after coverage termination.