CLM-2026-023434
Summit Heart Institute, Cardiology. Service 2026-01-13 at office (POS 11). Received 2026-02-22.
Member
Resolved through the identity graph
- Member
- Paul Garza
- Member ID
- none on golden record
- Date of birth
- 1981-06-15
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-405047
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- SELECT-EPO EPO group GRP-5099
- Coverage period
- 2024-05-01 to present
- Deductible
- $394.27 of $1,000.0039%
- Out-of-pocket maximum
- $912.83 of $2,000.0046%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 1318552993
- Network
- In network
- Rendering NPI
- 2355265150
- Location
- Tampa, FL · TIN 24-2775289
- 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 | $307.00 | $190.34 | — | — | PendedIDQ |
| Totals | $307.00 | $190.34 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-113856
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-000879; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-01-13: SELECT-EPO (EPO), effective 2024-05-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 40 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 Heart Institute (1318552993). | |
| 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 Heart Institute2026-01-13 13:59
Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-000879; payment withheld until the identity is confirmed. Eligibility: Active on 2026-01-13: SELECT-EPO (EPO), effective 2024-05-01. Coverage found by name and date of birth because the claim carried no usable member ID.
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
Clean claim, priced at contract rate.