CLM-2026-015730
Summit Internal Medicine Associates, Internal Medicine. Service 2026-03-27 at office (POS 11). Received 2026-05-02.
Member
Resolved through the identity graph
- Member
- Stephen Lawson
- Member ID
- UHC-40167-97
- Date of birth
- 1974-09-03
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-414045
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-3882
- Coverage period
- 2021-04-01 to present
- Deductible
- $719.70 of $1,500.0048%
- Out-of-pocket maximum
- $1,823.99 of $6,000.0030%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6465307315
- Network
- In network
- Rendering NPI
- 7196025820
- Location
- Dallas, TX · TIN 38-0331357
- Authorisation / referral
- none / REF436390
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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $232.00 | $143.84 | — | — | Review |
| Totals | $232.00 | $143.84 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- 3. J44.9 COPD, unspecified
- Patient account
- PA-499508
- 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-020384 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-27: NAVIGATE-HMO (HMO), effective 2021-04-01. | |
| 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 | Review | CO16 | Documentation incomplete: “Patient seen for chronic kidney disease, stage 3 unspecified. Note dictated; signature pen”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Summit Internal Medicine Associates2026-03-27 17:38
Patient seen for chronic kidney disease, stage 3 unspecified. Note dictated; signature pending.
- SystemSystem: Claims system2026-05-02 01:21
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-05-02 15:15
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 engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Patient seen for chronic kidney disease, stage 3 unspecified. Note dictated; signature pen”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009135 | 2026-05-19 | Riverside Imaging Center | $2,733.00 | Approved |
| CLM-2026-005625 | 2026-04-15 | Lakeside Bone and Joint Center | $152.00 | Approved |
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
Development letter outstanding.