CLM-2026-032706
Summit Family Practice, Family Medicine. Service 2026-01-21 at office (POS 11). Received 2026-06-11.
Member
Resolved through the identity graph
- Member
- Bryan Holmes
- Member ID
- UHC-32802-07
- Date of birth
- 2001-07-09
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-425033
- Relationship
- Child, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-2075
- Coverage period
- 2024-02-01 to present
- Deductible
- $1,323.85 of $1,500.0088%
- Out-of-pocket maximum
- $2,539.64 of $6,000.0042%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 3071022859
- Network
- In network
- Rendering NPI
- 5835761649
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $148.00 | $91.76 | — | — | DeniedCO29 |
| 2 | 36415 | Venipuncture | 25 | 1 | 1 | $24.00 | $14.88 | — | — | DeniedCO29 |
| 3 | 90471 | Immunization administration | — | 1 | 1 | $27.00 | $16.74 | — | — | DeniedCO29 |
| Totals | $199.00 | $123.38 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- Patient account
- PA-859242
- 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-014269 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-01-21: MEDICARE-ADV-B (MA), effective 2024-02-01. | |
| Timely filing | Fail | CO29 | Received 141 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 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 Practice2026-01-21 12:52
Patient seen for hyperlipidemia, unspecified.
- SystemSystem: Claims system2026-06-11 01:19
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-06-11 11:46
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 141 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-003473 | 2026-01-20 | Pinecrest Primary Care Associates | $531.00 | Approved |
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
Received after the timely-filing limit.