CLM-2026-029123
Summit Endocrine Associates, Endocrinology. Service 2026-05-06 at office (POS 11). Received 2026-05-29.
Member
Resolved through the identity graph
- Member
- Paul Powell
- Member ID
- UHC-90640-22
- Date of birth
- 1996-03-05
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-429922
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group -
- Coverage period
- 2021-01-01 to present
- Deductible
- $394.32 of $1,500.0026%
- Out-of-pocket maximum
- $1,928.79 of $4,500.0043%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Endocrine AssociatesEndocrinology · taxonomy 207RE0101X
- NPI
- 3880544135
- Network
- In network
- Rendering NPI
- 6675301538
- Location
- Dallas, TX · TIN 38-9625016
- 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 | $388.00 | $240.56 | $60.00 | $180.56 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $215.00 | $133.30 | $0.00 | $133.30 | Paid |
| 3 | 83036 | Hemoglobin A1c | 25 | 1 | 1 | $61.00 | $37.82 | $0.00 | $37.82 | Paid |
| Totals | $664.00 | $411.68 | $60.00 | $351.68 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-235421
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-032735 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-06: MEDICARE-ADV-A (MA), effective 2021-01-01. | |
| Timely filing | Pass | Received 23 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 Endocrine Associates (3880544135). | |
| 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 Endocrine Associates2026-05-06 18:57
Established patient presents with type 2 diabetes mellitus without complications; symptoms reviewed and vitals within expected range. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-05-29 03:37
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-05-29 13:33
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-235421.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
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
Authorisation must be confirmed with UM before payment.