Claims workbench/CLM-2026-004209
Professional claim · CMS-1500 · EDI 837P

CLM-2026-004209

Sunrise Medical Group, Internal Medicine. Service 2026-03-24 at office (POS 11). Received 2026-05-06.

DeniedOut of network
Billed
$82.00
1 line
Allowed
$36.90
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 10% coinsurance
Rules engine
Deny
CO204
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Roger Tran
Member ID
UHC-00583-18
Date of birth
1963-08-20
Identity
Verified2 records, confidence 0.96
Claim record
CLMCLM-400610
Relationship
Self, San Antonio, TX

Coverage and accumulators

Found by member ID

Plan
SELECT-EPO EPO group GRP-1461
Coverage period
2021-03-01 to present
Deductible
$313.30 of $500.0063%
Out-of-pocket maximum
$715.86 of $1,500.0048%
Copays
office $30.00, specialist $60.00, emergency $250.00
Physical therapy visits
18 of 20 used

Provider

Billing and rendering

Billing provider
Sunrise Medical Group
Internal Medicine · taxonomy 207R00000X
NPI
7336268843
Network
Out of network
Rendering NPI
4196759433
Location
Denver, CO · TIN 30-5353916
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
180053Comprehensive metabolic panel—11$82.00$36.90——DeniedCO204
Totals$82.00$36.90——
Diagnoses (ICD-10-CM)
  • 1. I10 Essential (primary) hypertensionprincipal
Claim header
Patient account
PA-269001
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

CheckResultCodeDetail
Member identityPassAttached to MBR-023300 (verified, link confidence 0.96).
EligibilityPassActive on 2026-03-24: SELECT-EPO (EPO), effective 2021-03-01.
Timely filingPassReceived 43 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkFailCO204Billing provider 7336268843 is out of network and the EPO plan has no out-of-network benefit.
Service not covered under the member's plan
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Sunrise Medical Group2026-03-24 13:15

    Patient seen for essential (primary) hypertension.

  • SystemSystem: Claims system2026-05-06 00:04

    Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineDenied2026-10-21 13:43
    Provider network: Billing provider 7336268843 is out of network and the EPO plan has no out-of-network benefit.

Other claims for this member

Same resolved identity

No other claims.

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

DeniedCO204scenario: Oon hmo

No out-of-network benefit on this plan.

Review queueMember identity