CLM-2026-027379
Summit Internal Medicine Associates, Internal Medicine. Service 2026-06-25 at office (POS 11). Received 2026-07-28.
Member
Resolved through the identity graph
- Member
- Russell Hicks
- Member ID
- UHC-25635-11
- Date of birth
- 1974-03-05
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-410229
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-1843
- Coverage period
- 2024-04-01 to present
- Deductible
- $178.34 of $1,500.0012%
- Out-of-pocket maximum
- $2,021.24 of $6,000.0034%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6465307315
- Network
- In network
- Rendering NPI
- 5610041993
- Location
- Dallas, TX · TIN 38-0331357
- 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 | $268.00 | $166.16 | $40.00 | $126.16 | Paid |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $367.00 | $227.54 | $0.00 | $227.54 | Paid |
| 3 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $86.00 | $53.32 | $0.00 | $53.32 | Paid |
| Totals | $721.00 | $447.02 | $40.00 | $407.02 | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- Patient account
- PA-994758
- 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-031257 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-25: SELECT-EPO (EPO), effective 2024-04-01. | |
| 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 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 Associates2026-06-25 18:03
Patient seen for type 2 diabetes mellitus with hyperglycemia.
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-2026-029118 | 2026-04-17 | Riverside Family Practice | $15.00 | 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.