CLM-2026-030120
Summit Endocrine Associates, Endocrinology. Service 2026-07-22 at office (POS 11). Received 2026-08-15.
Member
Resolved through the identity graph
- Member
- Camila Long
- Member ID
- UHC-01659-73
- Date of birth
- 2003-12-20
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-411241
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-1141
- Coverage period
- 2024-07-01 to 2026-02-12
- Deductible
- $1,137.21 of $2,500.0045%
- Out-of-pocket maximum
- $228.06 of $7,500.003%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Endocrine AssociatesEndocrinology · taxonomy 207RE0101X
- NPI
- 3880544135
- Network
- In network
- Rendering NPI
- 3463751974
- 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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $36.00 | $22.32 | — | — | DeniedCO27 |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $298.00 | $184.76 | — | — | DeniedCO27 |
| Totals | $334.00 | $207.08 | — | — | ||||||
- 1. E05.90 Thyrotoxicosis, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-836424
- 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 | Pass | Attached to MBR-006604 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-22 is after coverage terminated on 2026-02-12. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 24 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 Associates2026-07-22 15:34
Follow-up for thyrotoxicosis, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-15 04:26
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-08-15 13:38
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-07-22 is after coverage terminated on 2026-02-12.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.