CLM-2026-015797
Summit Endocrine Associates, Endocrinology. Service 2026-07-07 at office (POS 11). Received 2026-08-08.
Member
Resolved through the identity graph
- Member
- Stephen Ross
- Member ID
- UHC-82658-64
- Date of birth
- 1967-10-22
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-408661
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-1570
- Coverage period
- 2023-07-01 to present
- Deductible
- $1,581.68 of $2,500.0063%
- Out-of-pocket maximum
- $1,562.37 of $5,000.0031%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Endocrine AssociatesEndocrinology · taxonomy 207RE0101X
- NPI
- 3880544135
- Network
- In network
- Rendering NPI
- 9354148592
- Location
- Dallas, TX · TIN 38-9625016
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $354.00 | $219.48 | — | — | Review |
| Totals | $354.00 | $219.48 | — | — | ||||||
- 1. E05.90 Thyrotoxicosis, unspecifiedprincipal
- 2. E03.9 Hypothyroidism, unspecified
- Patient account
- PA-514825
- 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-019751 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-07-07: MEDICARE-ADV-A (MA), effective 2023-07-01. | |
| Timely filing | Pass | Received 32 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 | Review | CO16 | Documentation incomplete: “Established patient presents with thyrotoxicosis, unspecified; symptoms reviewed and vital”. 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 Endocrine Associates2026-07-07 10:51
Established patient presents with thyrotoxicosis, unspecified; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-08-08 05:23
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-08-08 16:24
Member services inquiry logged on this claim; member asked about the status of payment.
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: “Established patient presents with thyrotoxicosis, unspecified; symptoms reviewed and vital”.
Other claims for this member
Same resolved identity
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.