Claims workbench/CLM-2026-026256
Professional claim · CMS-1500 · EDI 837P

CLM-2026-026256

Summit Medical Group, Internal Medicine. Service 2026-04-30 at office (POS 11). Received 2026-06-01.

Approved
Billed
$316.00
1 line
Allowed
$195.92
contract rate applied
Plan pays
$155.92
approved
Member owes
$40.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Wayne Knight
Member ID
UHC-95604-13
Date of birth
1983-04-27
Identity
Verified2 records, confidence 0.96
Claim record
CLMCLM-409804
Relationship
Self, Chandler, AZ

Coverage and accumulators

Found by member ID

Plan
SELECT-EPO EPO group GRP-2513
Coverage period
2024-07-01 to present
Deductible
$2,299.30 of $3,500.0066%
Out-of-pocket maximum
$2,588.67 of $14,000.0018%
Copays
office $40.00, specialist $75.00, emergency $150.00
Physical therapy visits
22 of 20 used

Provider

Billing and rendering

Billing provider
Summit Medical Group
Internal Medicine · taxonomy 207R00000X
NPI
3585197395
Network
In network
Rendering NPI
4943634392
Location
Miami, FL · TIN 90-8787389
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199215Office visit, established patient, high complexity—11$316.00$195.92$40.00$155.92Paid
Totals$316.00$195.92$40.00$155.92
Diagnoses (ICD-10-CM)
  • 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
  • 2. I10 Essential (primary) hypertension
Claim header
Patient account
PA-699834
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

CheckResultCodeDetail
Member identityPassAttached to MBR-033218 (verified, link confidence 0.96).
EligibilityPassActive on 2026-04-30: SELECT-EPO (EPO), effective 2024-07-01.
Timely filingPassReceived 32 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Summit Medical Group (3585197395).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin 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 Medical Group2026-04-30 15:25

    Established patient presents with chronic kidney disease, stage 3 unspecified; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Explanation of benefits

What the member will see

Amount billed
$316.00
Plan discount
$120.08
contracted rate
Plan paid
$155.92
You may owe
$40.00
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-21 13:43
    Clean claim.

Other claims for this member

Same resolved identity

No other claims.

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.

Review queueMember identity