CLM-2026-013332
Summit Internal Medicine Associates, Internal Medicine. Service 2026-03-02 to 2026-03-05 at inpatient hospital (POS 21). Received 2026-03-04.
Member
Resolved through the identity graph
- Member
- Kayla Valdez
- Member ID
- UHC-41143-37
- Date of birth
- 1938-05-23
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-432305
- Relationship
- Child, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-9072
- Coverage period
- 2024-12-01 to present
- Deductible
- $501.92 of $1,000.0050%
- Out-of-pocket maximum
- $924.21 of $2,000.0046%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6465307315
- Network
- In network
- Rendering NPI
- 1613060353
- Location
- Dallas, TX · TIN 38-0331357
- 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 | — | 1 | 1 | $229.00 | $125.95 | $125.95 | $0.00 | Paid |
| Totals | $229.00 | $125.95 | $125.95 | $0.00 | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-178648
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-03-02 to 2026-03-04
- 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-004577 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-02: MEDICARE-ADV-A (MA), effective 2024-12-01. | |
| Timely filing | Pass | Received -1 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 Internal Medicine Associates (6465307315). | |
| 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 Internal Medicine Associates2026-03-05 14:53
Patient seen for type 2 diabetes mellitus with hyperglycemia.
Attachments
Documents received with the claim
- Itemized billitemized_PA-178648.pdf6 pages
Itemised statement totalling $229.00 across 1 line.
Explanation of benefits
What the member will see
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-2026-018018 | 2026-06-11 | Summit Counseling Center | $630.00 | Approved |
| CLM-2026-002148 | 2025-12-17 | Desert Internal Medicine Associates | $276.00 | Approved |
| CLM-2026-001728 | 2025-12-21 | Unity Primary Care Associates | $460.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.