CLM-2026-001526
Sunrise GI Associates, Gastroenterology. Service 2026-06-02 at outpatient hospital (POS 22). Received 2026-06-26.
Member
Resolved through the identity graph
- Member
- Roger Crawford
- Member ID
- UHC-92649-44
- Date of birth
- 1966-01-21
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-402366
- Relationship
- Spouse, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-0937
- Coverage period
- 2025-08-01 to present
- Deductible
- $304.65 of $2,500.0012%
- Out-of-pocket maximum
- $2,352.82 of $5,000.0047%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 3324417310
- Network
- In network
- Rendering NPI
- 5355077509
- Location
- Phoenix, AZ · TIN 97-9024956
- Authorisation / referral
- none / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1 | $337.00 | $185.35 | — | — | DeniedCO197 |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1,2 | $2,171.00 | $1,194.05 | — | — | DeniedCO197 |
| Totals | $2,508.00 | $1,379.40 | — | — | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
- Patient account
- PA-442704
- 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-000491 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-02: UNKNOWN (PPO), effective 2025-08-01. | |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 43239 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Sunrise GI Associates (3324417310). | |
| 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: Sunrise GI Associates2026-06-02 17:09
Established patient presents with gastro-esophageal reflux disease without esophagitis; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-26 00:46
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-06-26 11:50
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-442704.pdf5 pages
Itemised statement totalling $2508.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 43239 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
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
Precertification required and absent.