CLM-2026-010861
Summit Endocrine Associates, Endocrinology. Service 2026-08-02 at office (POS 11). Received 2026-08-16.
Member
Resolved through the identity graph
- Member
- Tyler Anderson
- Member ID
- none on golden record
- Date of birth
- 2002-09-16
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-432762
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- OPTIONS-PPO PPO group GRP-9337
- Coverage period
- 2025-04-01 to 2026-08-24
- Deductible
- $2,094.54 of $3,500.0060%
- Out-of-pocket maximum
- $4,904.81 of $10,500.0047%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Endocrine AssociatesEndocrinology · taxonomy 207RE0101X
- NPI
- 3880544135
- Network
- In network
- Rendering NPI
- 5812025356
- Location
- Dallas, TX · TIN 38-9625016
- 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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $71.00 | $44.02 | — | — | PendedIDQ |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 2 | $384.00 | $238.08 | — | — | PendedIDQ |
| Totals | $455.00 | $282.10 | — | — | ||||||
- 1. E03.9 Hypothyroidism, unspecifiedprincipal
- Patient account
- PA-358482
- 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-001826; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-08-02: OPTIONS-PPO (PPO), effective 2025-04-01, terms 2026-08-24. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 14 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 Endocrine Associates (3880544135). | |
| 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 Endocrine Associates2026-08-02 18:50
Follow-up for hypothyroidism, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-001826; payment withheld until the identity is confirmed. Eligibility: Active on 2026-08-02: OPTIONS-PPO (PPO), effective 2025-04-01, terms 2026-08-24. Coverage found by name and date of birth because the claim carried no usable member ID.
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
Clean claim, priced at contract rate.