CLM-2026-010786
Summit Medical Group, Internal Medicine. Service 2026-03-24 to 2026-03-28 at inpatient hospital (POS 21). Received 2026-05-08.
Member
Resolved through the identity graph
- Member
- Kayla Cook
- Member ID
- UHC-36140-39
- Date of birth
- 1984-01-02
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-402058
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3536
- Coverage period
- 2022-07-01 to present
- Deductible
- $52.38 of $500.0010%
- Out-of-pocket maximum
- $393.42 of $2,000.0020%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3585197395
- Network
- In network
- Rendering NPI
- 1649381716
- 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 | 59 | 1 | 1 | $240.00 | $132.00 | — | — | Review |
| 2 | 99215 | Office visit, established patient, high complexity | 59 | 1 | 1 | $393.00 | $216.15 | — | — | Review |
| Totals | $633.00 | $348.15 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-477923
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-03-24 to 2026-03-28
- 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-028430 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-24: OPTIONS-PPO (PPO), effective 2022-07-01. | |
| Timely filing | Pass | Received 41 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) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Group2026-03-28 12:01
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
- SystemSystem: Claims system2026-05-08 03:02
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Itemized billitemized_PA-477923.pdf8 pages
Itemised statement totalling $633.00 across 2 lines.
- Medical recordrecords_PA-477923.pdf9 pages
Operative note describing procedures at two distinct anatomical sites.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
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
Modifier 59 supported: distinct anatomical site documented.