CLM-2026-023816
Summit Family Practice, Family Medicine. Service 2026-04-11 at office (POS 11). Received 2026-04-26.
Member
Resolved through the identity graph
- Member
- Jean Lucas
- Member ID
- UHC-13467-31
- Date of birth
- 1940-03-20
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-401355
- Relationship
- Child, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-4037
- Coverage period
- 2021-01-01 to 2026-03-17
- Deductible
- $206.44 of $500.0041%
- Out-of-pocket maximum
- $314.81 of $1,500.0021%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 3071022859
- Network
- In network
- Rendering NPI
- 7675772868
- Location
- Minneapolis, MN · TIN 67-3208363
- 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 | 90471 | Immunization administration | — | 1 | 1 | $37.00 | $22.94 | — | — | DeniedCO27 |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $253.00 | $156.86 | — | — | DeniedCO27 |
| Totals | $290.00 | $179.80 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-991819
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-021753 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-11 is after coverage terminated on 2026-03-17. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 15 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 Family Practice (3071022859). | |
| 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 Family Practice2026-04-11 18:11
Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-04-26 04:19
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-04-26 15:40
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-04-11 is after coverage terminated on 2026-03-17.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-006452 | 2026-02-12 | Mesa Physical Therapy | $196.00 | 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
Service after coverage termination.