CLM-2026-004537
Sunrise Digestive Health Center, Gastroenterology. Service 2026-05-26 at outpatient hospital (POS 22). Received 2026-06-21.
Member
Resolved through the identity graph
- Member
- Jesse Barnes
- Member ID
- UHC-14334-26
- Date of birth
- 1969-03-23
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-416502
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-4283
- Coverage period
- 2021-03-01 to present
- Deductible
- $449.14 of $500.0090%
- Out-of-pocket maximum
- $512.26 of $2,000.0026%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 5701797651
- Network
- Out of network
- Rendering NPI
- 9302198426
- Location
- Nashville, TN · TIN 99-4024660
- Authorisation / referral
- none / REF222054
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 | $204.00 | $91.80 | — | — | DeniedCO204 |
| Totals | $204.00 | $91.80 | — | — | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- Patient account
- PA-915780
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-006096 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-26: CORE-HMO (HMO), effective 2021-03-01. | |
| Timely filing | Pass | Received 26 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-004536, billed by a different provider. Possible duplicate |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Fail | CO204 | Billing provider 5701797651 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Center2026-05-26 17:35
Established patient presents with irritable bowel syndrome with diarrhea; symptoms reviewed and vitals within expected range. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-06-21 03:13
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-06-21 08:48
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-915780.pdf6 pages
Itemised statement totalling $204.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Same member, date of service and procedures as CLM-2026-004536, billed by a different provider. Provider network: Billing provider 5701797651 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004536 | 2026-05-26 | Unity Digestive Health Center | $204.00 | Approved |
| CLM-2026-031962 | 2026-03-20 | Valley Bone and Joint Center | $407.00 | Denied |
| CLM-2026-031961 | 2026-03-20 | Lakeside Bone and Joint Center | $407.00 | 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
Different billing provider; separately payable.