CLM-2026-022745
Summit Primary Care Associates, Family Medicine. Service 2025-12-26 at office (POS 11). Received 2026-01-22.
Member
Resolved through the identity graph
- Member
- Willie Sims
- Member ID
- UHC-08712-31
- Date of birth
- 1959-05-14
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-430600
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-9114
- Coverage period
- 2024-05-01 to present
- Deductible
- $543.91 of $1,000.0054%
- Out-of-pocket maximum
- $760.56 of $2,000.0038%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 1481685224
- Network
- In network
- Rendering NPI
- 6840281938
- Location
- Denver, CO · TIN 20-1905659
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $243.00 | $150.66 | — | — | DeniedCO18 |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 2 | $189.00 | $117.18 | — | — | DeniedCO18 |
| Totals | $432.00 | $267.84 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-730330
- 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-002738 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-26: OPTIONS-PPO (PPO), effective 2024-05-01. | |
| Timely filing | Pass | Received 27 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-022744: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Summit Primary Care Associates (1481685224). | |
| 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 Primary Care Associates2025-12-26 13:40
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-01-22 01:58
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-022744: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033707 | 2026-05-03 | Northgate Cardiovascular Associates | $270.00 | Approved |
| CLM-2026-022744 | 2025-12-26 | Summit Primary Care Associates | $432.00 | Approved |
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
Exact duplicate of an earlier submission.