CLM-2026-031060
Summit Family Practice, Family Medicine. Service 2026-01-16 at office (POS 11). Received 2026-02-06.
Member
Resolved through the identity graph
- Member
- Dorothy Hicks
- Member ID
- UHC-59594-14
- Date of birth
- 1941-08-16
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-405072
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-3095
- Coverage period
- 2021-05-01 to present
- Deductible
- $114.15 of $500.0023%
- Out-of-pocket maximum
- $614.81 of $1,500.0041%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 3071022859
- Network
- In network
- Rendering NPI
- 8268536991
- Location
- Minneapolis, MN · TIN 67-3208363
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $237.00 | $146.94 | — | — | Review |
| 2 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $296.00 | $183.52 | — | — | Review |
| Totals | $533.00 | $330.46 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- Patient account
- PA-950329
- 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-009857 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-16: NAVIGATE-HMO (HMO), effective 2021-05-01. | |
| Timely filing | Pass | Received 21 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-031059, billed by a different provider. Possible duplicate |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Summit Family Practice (3071022859). | |
| 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 Practice2026-01-16 10:06
Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vitals within expected range. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-02-06 01:38
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-02-06 16:39
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Duplicate check: Same member, date of service and procedures as CLM-2026-031059, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031059 | 2026-01-16 | Canyon Primary Care Associates | $533.00 | Approved |
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
Different billing provider; separately payable.