Professional claim · CMS-1500 · EDI 837P
CLM-2026-033717
Summit Family Practice, Family Medicine. Service 2026-04-06 at office (POS 11). Received 2026-04-21.
Denied
Billed
$514.00
3 lines
Allowed
$318.68
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 10% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Olivia Pena
- Member ID
- UHC-64907-39
- Date of birth
- 1962-11-01
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-412407
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-8168
- Coverage period
- 2022-09-01 to 2026-01-09
- Deductible
- $2,693.86 of $3,500.0077%
- Out-of-pocket maximum
- $2,078.88 of $10,500.0020%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 9865039744
- Network
- In network
- Rendering NPI
- 1721393977
- Location
- Scottsdale, AZ · TIN 65-7813683
- 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 | 36415 | Venipuncture | — | 1 | 1 | $21.00 | $13.02 | — | — | DeniedCO27 |
| 2 | 99395 | Preventive visit, 18-39 years | — | 1 | 1,2 | $254.00 | $157.48 | — | — | DeniedCO27 |
| 3 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $239.00 | $148.18 | — | — | DeniedCO27 |
| Totals | $514.00 | $318.68 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- 3. M54.50 Low back pain, unspecified
Claim header
- Patient account
- PA-848648
- 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-026987 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-06 is after coverage terminated on 2026-01-09. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 15 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 Family Practice (9865039744). | |
| 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. |
Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Summit Family Practice2026-04-06 11:06
Patient seen for hyperlipidemia, unspecified.
- SystemSystem: Claims system2026-04-21 00:44
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-04-06 is after coverage terminated on 2026-01-09.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010639 | 2026-05-03 | Lakeside Behavioral Health | $2,748.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Denied by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
DeniedCO27scenario: Coverage terminated
Service after coverage termination.