Professional claim · CMS-1500 · EDI 837P
CLM-2026-013065
Summit Medical Group, Internal Medicine. Service 2026-06-10 at office (POS 11). Received 2026-06-12.
Approved
Billed
$351.00
2 lines
Allowed
$217.62
contract rate applied
Plan pays
$192.62
approved
Member owes
$25.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Daniel Holmes
- Member ID
- UHC-72010-71
- Date of birth
- 1953-11-18
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-431615
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-4520
- Coverage period
- 2025-10-01 to present
- Deductible
- $1,144.76 of $1,500.0076%
- Out-of-pocket maximum
- $1,298.80 of $6,000.0022%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3585197395
- Network
- In network
- Rendering NPI
- 9263950203
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $70.00 | $43.40 | $25.00 | $18.40 | Paid |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 1,2 | $281.00 | $174.22 | $0.00 | $174.22 | Paid |
| Totals | $351.00 | $217.62 | $25.00 | $192.62 | ||||||
Diagnoses (ICD-10-CM)
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- 3. N18.30 Chronic kidney disease, stage 3 unspecified
Claim header
- Patient account
- PA-261490
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-034588 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-10: OPTIONS-PPO (PPO), effective 2025-10-01. | |
| Timely filing | Pass | Received 2 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. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Summit Medical Group2026-06-10 14:10
Patient seen for unspecified atrial fibrillation.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$351.00
Plan discount
$133.38
contracted rate
Plan paid
$192.62
You may owe
$25.00
copay, deductible and coinsurance
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-2026-005407 | 2026-08-12 | Mesa Family Practice | $528.00 | Approved |
| CLM-2026-020099 | 2026-06-22 | Heritage Community Hospital | $3,713.00 | Approved |
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.