CLM-2026-014863
Summit Internal Medicine Associates, Internal Medicine. Service 2026-08-13 at office (POS 11). Received 2026-09-18.
Member
Resolved through the identity graph
- Member
- Ann Le
- Member ID
- UHC-83217-03
- Date of birth
- 1945-12-25
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-409654
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2399
- Coverage period
- 2022-01-01 to 2026-06-11
- Deductible
- $654.61 of $1,500.0044%
- Out-of-pocket maximum
- $1,921.85 of $6,000.0032%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6465307315
- Network
- In network
- Rendering NPI
- 8514351732
- Location
- Dallas, TX · TIN 38-0331357
- 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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $86.00 | $53.32 | — | — | DeniedCO27 |
| Totals | $86.00 | $53.32 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-549098
- 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-021659 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-13 is after coverage terminated on 2026-06-11. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 36 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 Associates2026-08-13 09:56
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-18 02:07
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 2026-08-13 is after coverage terminated on 2026-06-11.
Other claims for this member
Same resolved identity
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.