CLM-2026-027160
Summit Family Practice, Family Medicine. Service 2026-04-20 at office (POS 11). Received 2026-05-23.
Member
Resolved through the identity graph
- Member
- Mei Torres
- Member ID
- UHC-14646-55
- Date of birth
- 1955-05-20
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-402493
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-2394
- Coverage period
- 2024-03-01 to present
- Deductible
- $332.51 of $500.0067%
- Out-of-pocket maximum
- $18.61 of $1,000.002%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 9865039744
- Network
- In network
- Rendering NPI
- 6589466476
- Location
- Scottsdale, AZ · TIN 65-7813683
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $284.00 | $176.08 | — | — | PendedIDQ |
| 2 | 90471 | Immunization administration | — | 1 | 1 | $31.00 | $19.22 | — | — | PendedIDQ |
| 3 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $297.00 | $184.14 | — | — | PendedIDQ |
| Totals | $612.00 | $379.44 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-383870
- 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 | Fail | IDQ | Member record is in open steward case CASE-002284; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-04-20: NULL (PPO), effective 2024-03-01. | |
| Timely filing | Pass | Received 33 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 (9865039744). | |
| 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 Practice2026-04-20 17:51
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-002284; payment withheld until the identity is confirmed.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.