CLM-2026-014600
Summit Endocrine Associates, Endocrinology. Service 2026-09-05 at office (POS 11). Received 2026-10-18.
Member
Resolved through the identity graph
- Member
- Angela Bailey
- Member ID
- UHC-80041-28
- Date of birth
- 1948-09-23
- Identity
- Verified4 records, confidence 0.98
- Claim record
- CLMCLM-416080
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9632
- Coverage period
- 2023-11-01 to 2026-04-03
- Deductible
- $37.20 of $1,000.004%
- Out-of-pocket maximum
- $1,060.12 of $3,000.0035%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Endocrine AssociatesEndocrinology · taxonomy 207RE0101X
- NPI
- 3880544135
- Network
- In network
- Rendering NPI
- 1187805464
- Location
- Dallas, TX · TIN 38-9625016
- Authorisation / referral
- none / REF105175
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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $294.00 | $182.28 | — | — | DeniedCO27 |
| 2 | 83036 | Hemoglobin A1c | 25 | 1 | 2 | $61.00 | $37.82 | — | — | DeniedCO27 |
| Totals | $355.00 | $220.10 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E03.9 Hypothyroidism, unspecified
- Patient account
- PA-891534
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-028689 (verified, link confidence 0.98). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-05 is after coverage terminated on 2026-04-03. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 43 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 Associates2026-09-05 13:08
Patient seen for type 2 diabetes mellitus without complications.
- SystemSystem: Claims system2026-10-18 03:45
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-10-18 10:23
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-09-05 is after coverage terminated on 2026-04-03.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-013528 | 2026-05-12 | Mesa Dermatology Clinic | $782.00 | Denied |
| CLM-2026-019966 | 2026-04-13 | Northgate Primary Care Associates | $270.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.