CLM-2026-003630
Sunrise Family Practice, Family Medicine. Service 2026-01-09 at office (POS 11). Received 2026-02-12.
Member
Resolved through the identity graph
- Member
- Benjamin Duncan
- Member ID
- UHC-06987-44
- Date of birth
- 1957-04-07
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-423570
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5281
- Coverage period
- 2023-09-01 to present
- Deductible
- $84.58 of $3,500.002%
- Out-of-pocket maximum
- $2,305.84 of $10,500.0022%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 3793775529
- Network
- In network
- Rendering NPI
- 5019797534
- Location
- Miami, FL · TIN 77-9706037
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $323.00 | $200.26 | — | — | DeniedCO18 |
| 2 | 36415 | Venipuncture | — | 1 | 1 | $25.00 | $15.50 | — | — | DeniedCO18 |
| 3 | 99214 | Office visit, established patient, moderate complexity | 25 | 1 | 1 | $290.00 | $179.80 | — | — | DeniedCO18 |
| Totals | $638.00 | $395.56 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-787021
- 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-004842 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-09: CHOICE-PLUS-PPO (PPO), effective 2023-09-01. | |
| Timely filing | Pass | Received 34 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-003629: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Sunrise Family Practice (3793775529). | |
| 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 Family Practice2026-01-09 18:15
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-02-12 00:25
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-02-12 15:06
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-003629: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020650 | 2026-04-05 | Pinecrest Physical Therapy | $259.00 | Approved |
| CLM-2026-003629 | 2026-01-09 | Sunrise Family Practice | $638.00 | 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
Exact duplicate of an earlier submission.