CLM-2026-023778
Summit Internal Medicine Associates, Internal Medicine. Service 2026-07-12 to 2026-07-15 at inpatient hospital (POS 21). Received 2026-08-23.
Member
Resolved through the identity graph
- Member
- Walter Hudson
- Member ID
- UHC-10004-82
- Date of birth
- 1939-11-17
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-423472
- Relationship
- Spouse, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3014
- Coverage period
- 2024-12-01 to present
- Deductible
- $875.86 of $2,500.0035%
- Out-of-pocket maximum
- $808.12 of $5,000.0016%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6465307315
- Network
- In network
- Rendering NPI
- 9609722688
- Location
- Dallas, TX · TIN 38-0331357
- Authorisation / referral
- none / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $181.00 | $99.55 | $99.55 | $0.00 | Paid |
| Totals | $181.00 | $99.55 | $99.55 | $0.00 | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-257313
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-07-12 to 2026-07-16
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-013972 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-12: OPTIONS-PPO (PPO), effective 2024-12-01. | |
| Timely filing | Pass | Received 39 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 Internal Medicine Associates (6465307315). | |
| 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 Internal Medicine Associates2026-07-15 16:57
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
- Itemized billitemized_PA-257313.pdf2 pages
Itemised statement totalling $181.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016362 | 2026-03-21 | Mesa Reference Lab | $1,926.00 | Needs review |
| CLM-2026-016331 | 2026-02-12 | Pinecrest Family Practice | $193.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.