CLM-2026-032135
Summit Endocrine Associates, Endocrinology. Service 2026-03-25 at office (POS 11). Received 2026-04-26.
Member
Resolved through the identity graph
- Member
- Bryan Black
- Member ID
- UHC-11439-98
- Date of birth
- 1940-01-26
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-427171
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-2259
- Coverage period
- 2024-12-01 to present
- Deductible
- $388.23 of $1,000.0039%
- Out-of-pocket maximum
- $86.37 of $4,000.002%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Endocrine AssociatesEndocrinology · taxonomy 207RE0101X
- NPI
- 3880544135
- Network
- In network
- Rendering NPI
- 3125448589
- Location
- Dallas, TX · TIN 38-9625016
- Authorisation / referral
- none / REF718623
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 | 59 | 1 | 1 | $74.00 | $45.88 | — | — | Review |
| 2 | 99215 | Office visit, established patient, high complexity | 59 | 1 | 1 | $371.00 | $230.02 | — | — | Review |
| 3 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $330.00 | $204.60 | — | — | Review |
| Totals | $775.00 | $480.50 | — | — | ||||||
- 1. E03.9 Hypothyroidism, unspecifiedprincipal
- Patient account
- PA-746031
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-003456 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-03-25: CORE-HMO (HMO), effective 2024-12-01. | |
| Timely filing | Pass | Received 32 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) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Associates2026-03-25 11:54
Patient seen for hypothyroidism, unspecified. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-04-26 05:48
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-04-26 10:07
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Medical recordrecords_PA-746031.pdf15 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-003589 | 2026-09-03 | Sunrise Imaging Center | $3,641.00 | Denied |
| CLM-2026-009922 | 2026-07-06 | Canyon Community Hospital | $3,410.00 | Needs review |
| CLM-2026-020616 | 2025-12-04 | Pinecrest Bone and Joint Center | $11,309.00 | 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
Bundled code pair; modifier 59 not supported by the operative note.