CLM-2026-023836
Summit Medical Group, Internal Medicine. Service 2026-05-06 at office (POS 11). Received 2026-05-13.
Member
Resolved through the identity graph
- Member
- Nancy Bennett
- Member ID
- UHC-28664-92
- Date of birth
- 1940-03-16
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-402251
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3273
- Coverage period
- 2025-05-01 to present
- Deductible
- $89.82 of $1,000.009%
- Out-of-pocket maximum
- $398.47 of $2,000.0020%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3585197395
- Network
- In network
- Rendering NPI
- 6558121565
- Location
- Miami, FL · TIN 90-8787389
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $307.00 | $190.34 | $20.00 | $170.34 | Paid |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $42.00 | $26.04 | $0.00 | $26.04 | Paid |
| 3 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $301.00 | $186.62 | $0.00 | $186.62 | Paid |
| Totals | $650.00 | $403.00 | $20.00 | $383.00 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-800646
- 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-017390 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-05-06: UNKNOWN (PPO), effective 2025-05-01. | |
| Timely filing | Pass | Received 7 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 Medical Group (3585197395). | |
| 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 Medical Group2026-05-06 10:06
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
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-2026-026144 | 2026-08-21 | Northgate Internal Medicine Associates | $208.00 | 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.