CLM-2026-030558
Summit Internal Medicine Associates, Internal Medicine. Service 2026-05-28 at office (POS 11). Received 2026-06-18.
Member
Resolved through the identity graph
- Member
- Andrew Munoz
- Member ID
- UHC-13020-18
- Date of birth
- 1991-03-07
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-402023
- Relationship
- Child, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-3586
- Coverage period
- 2024-05-01 to present
- Deductible
- $88.66 of $500.0018%
- Out-of-pocket maximum
- $667.43 of $1,500.0044%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6465307315
- Network
- In network
- Rendering NPI
- 1759906484
- 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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $115.00 | $71.30 | $30.00 | $41.30 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $284.00 | $176.08 | $0.00 | $176.08 | Paid |
| Totals | $399.00 | $247.38 | $30.00 | $217.38 | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-871802
- 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-034569 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-28: NAVIGATE-HMO (HMO), effective 2024-05-01. | |
| Timely filing | Pass | Received 21 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 Associates2026-05-28 17:06
Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-06-18 01:09
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)2026-06-18 15:29
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-871802.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.