CLM-2026-003065
Sunrise Digestive Health Center, Gastroenterology. Service 2026-03-24 at outpatient hospital (POS 22). Received 2026-03-30.
Member
Resolved through the identity graph
- Member
- Santiago Miller
- Member ID
- UHC-98037-76
- Date of birth
- 1951-02-23
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-411569
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-5273
- Coverage period
- 2023-01-01 to 2026-01-15
- Deductible
- $344.86 of $2,500.0014%
- Out-of-pocket maximum
- $1,668.06 of $10,000.0017%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 3482505971
- Network
- In network
- Rendering NPI
- 7901909912
- Location
- Los Angeles, CA · TIN 56-5803475
- Authorisation / referral
- PA2025438740 / REF250090
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 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1 | $2,709.00 | $1,489.95 | — | — | DeniedCO27 |
| Totals | $2,709.00 | $1,489.95 | — | — | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- Patient account
- PA-324181
- 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-022952 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-03-24 is after coverage terminated on 2026-01-15. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 6 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025438740 on file for 45378. | |
| Provider network | Pass | In-network provider Sunrise Digestive Health Center (3482505971). | |
| 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 Digestive Health Center2026-03-24 18:18
Established patient presents with irritable bowel syndrome with diarrhea; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-03-30 04:25
Attachments
Documents received with the claim
- Prior auth letterPA2025438740_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-03-24 to 2026-06-22.
- Itemized billitemized_PA-324181.pdf2 pages
Itemised statement totalling $2709.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-03-24 is after coverage terminated on 2026-01-15.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009276 | 2026-05-04 | Sunrise Cardiovascular Associates | $679.00 | Denied |
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
Service after coverage termination.