Claims workbench/CLM-2026-023391
Professional claim · CMS-1500 · EDI 837P

CLM-2026-023391

Summit Medical Group, Internal Medicine. Service 2026-09-04 at office (POS 11). Received 2026-09-17.

Approved
Billed
$72.00
1 line
Allowed
$44.64
contract rate applied
Plan pays
$19.64
approved
Member owes
$25.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Donna Renolds
Member ID
UHC-53206-63
Date of birth
1990-12-09
Identity
Verified3 records, confidence 0.99
Claim record
CLMCLM-416934
Relationship
Spouse, Charlotte, NC

Coverage and accumulators

Found by member ID

Plan
CORE-HMO HMO group GRP-8240
Coverage period
2025-04-01 to present
Deductible
$865.58 of $2,500.0035%
Out-of-pocket maximum
$444.18 of $7,500.006%
Copays
office $25.00, specialist $75.00, emergency $250.00
Physical therapy visits
2 of 20 used

Provider

Billing and rendering

Billing provider
Summit Medical Group
Internal Medicine · taxonomy 207R00000X
NPI
3585197395
Network
In network
Rendering NPI
9350214604
Location
Miami, FL · TIN 90-8787389
Authorisation / referral
none / REF622713

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
180053Comprehensive metabolic panel—11$72.00$44.64$25.00$19.64Paid
Totals$72.00$44.64$25.00$19.64
Diagnoses (ICD-10-CM)
  • 1. I10 Essential (primary) hypertensionprincipal
  • 2. I48.91 Unspecified atrial fibrillation
Claim header
Patient account
PA-292436
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 0 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-038983 (verified, link confidence 0.99).
EligibilityPassActive on 2026-09-04: CORE-HMO (HMO), effective 2025-04-01.
Timely filingPassReceived 13 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Summit Medical Group (3585197395).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Summit Medical Group2026-09-04 15:17

    Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Explanation of benefits

What the member will see

Amount billed
$72.00
Plan discount
$27.36
contracted rate
Plan paid
$19.64
You may owe
$25.00
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-21 13:43
    Clean claim.

Other claims for this member

Same resolved identity

ClaimServiceProviderBilledStatus
CLM-2026-0233922026-09-04Summit Medical Group$72.00Denied
CLM-2026-0238452026-08-21Mesa Physical Therapy$6,756.00Needs review

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

Clean claim: the rules engine approved it, so no AI review was needed.

Examiner decision

Approved by Claims rules engine; an examiner may still override

Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queueMember identity