CLM-2026-023380
Summit Medical Group, Internal Medicine. Service 2025-10-21 at office (POS 11). Received 2026-03-20.
Member
Resolved through the identity graph
- Member
- Nicholas Santos
- Member ID
- UHC-65934-13
- Date of birth
- 1973-05-25
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-428414
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-3756
- Coverage period
- 2024-12-01 to 2026-02-12
- Deductible
- $132.33 of $500.0026%
- Out-of-pocket maximum
- $731.45 of $2,000.0037%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3585197395
- Network
- In network
- Rendering NPI
- 9653712601
- Location
- Miami, FL · TIN 90-8787389
- 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 | $413.00 | $256.06 | — | — | DeniedCO29 |
| 2 | 99214 | Office visit, established patient, moderate complexity | 25 | 1 | 1 | $249.00 | $154.38 | — | — | DeniedCO29 |
| Totals | $662.00 | $410.44 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- Patient account
- PA-470535
- 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-001937 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-10-21: MEDICARE-ADV-A (MA), effective 2024-12-01, terms 2026-02-12. | |
| Timely filing | Fail | CO29 | Received 150 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Medical Group (3585197395). | |
| 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 Medical Group2025-10-21 17:03
Follow-up for type 2 diabetes mellitus with hyperglycemia. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-03-20 06:14
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 150 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-013917 | 2026-07-09 | Desert Internal Medicine Associates | $215.00 | Denied |
| CLM-2026-022342 | 2025-12-25 | Heritage GI Associates | $2,257.00 | Denied |
| CLM-2026-022341 | 2025-12-25 | Heritage GI Associates | $2,257.00 | 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
Received after the timely-filing limit.