Professional claim · CMS-1500 · Paper
CLM-2026-023594
Summit Endocrine Associates, Endocrinology. Service 2026-02-05 at office (POS 11). Received 2026-03-14.
Approved
Billed
$603.00
3 lines
Allowed
$373.86
contract rate applied
Plan pays
$298.86
approved
Member owes
$75.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Angela Espinoza
- Member ID
- UHC-96990-15
- Date of birth
- 1979-07-09
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-400235
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5088
- Coverage period
- 2025-11-01 to present
- Deductible
- $907.32 of $2,500.0036%
- Out-of-pocket maximum
- $3,043.23 of $7,500.0041%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Endocrine AssociatesEndocrinology · taxonomy 207RE0101X
- NPI
- 3880544135
- Network
- In network
- Rendering NPI
- 8126057156
- Location
- Dallas, TX · TIN 38-9625016
- Authorisation / referral
- none / REF234783
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 | $325.00 | $201.50 | $75.00 | $126.50 | Paid |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 1,2 | $51.00 | $31.62 | $0.00 | $31.62 | Paid |
| 3 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1,2 | $227.00 | $140.74 | $0.00 | $140.74 | Paid |
| Totals | $603.00 | $373.86 | $75.00 | $298.86 | ||||||
Diagnoses (ICD-10-CM)
- 1. E03.9 Hypothyroidism, unspecifiedprincipal
- 2. E05.90 Thyrotoxicosis, unspecified
Claim header
- Patient account
- PA-513733
- 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
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-017663 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-05: NAVIGATE-HMO (HMO), effective 2025-11-01. | |
| Timely filing | Pass | Received 37 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 | Pass | Required documentation present. | |
| High-dollar review | Pass | Within 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 Endocrine Associates2026-02-05 10:10
Follow-up for hypothyroidism, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$603.00
Plan discount
$229.14
contracted rate
Plan paid
$298.86
You may owe
$75.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001010 | 2026-08-12 | Northgate Clinical Laboratories | $55.00 | Approved |
| CLM-2026-016826 | 2026-03-25 | Sunrise Imaging Center | $3,501.00 | Denied |
| CLM-2026-030300 | 2026-01-25 | Heritage Primary Care Associates | $304.00 | Approved |
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.