CLM-2026-004694
Sunrise GI Associates, Gastroenterology. Service 2026-06-06 at outpatient hospital (POS 22). Received 2026-06-11.
Member
Resolved through the identity graph
- Member
- Rebecca Robinson
- Member ID
- UHC-71751-18
- Date of birth
- 1980-09-09
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-405912
- Relationship
- Spouse, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5079
- Coverage period
- 2021-03-01 to present
- Deductible
- $1,265.62 of $1,500.0084%
- Out-of-pocket maximum
- $1,730.47 of $4,500.0038%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 3324417310
- Network
- In network
- Rendering NPI
- 1390961104
- Location
- Phoenix, AZ · TIN 97-9024956
- Authorisation / referral
- none / REF424683
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 | $254.00 | $139.70 | $139.70 | $0.00 | Paid |
| Totals | $254.00 | $139.70 | $139.70 | $0.00 | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- 2. Z12.11 Encounter for screening for malignant neoplasm of colon
- Patient account
- PA-618133
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-021205 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-06: NAVIGATE-HMO (HMO), effective 2021-03-01. | |
| Timely filing | Pass | Received 5 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| 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 Associates2026-06-06 14:06
Patient seen for irritable bowel syndrome with diarrhea.
Attachments
Documents received with the claim
- Itemized billitemized_PA-618133.pdf7 pages
Itemised statement totalling $254.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031261 | 2026-03-18 | Valley Community Hospital | $2,101.00 | Needs review |
| CLM-2026-011079 | 2026-02-05 | Heritage Primary Care Associates | $266.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.