CLM-2026-004715
Sunrise Digestive Health Center, Gastroenterology. Service 2026-06-08 at office (POS 11). Received 2026-07-03.
Member
Resolved through the identity graph
- Member
- Jacob Hall
- Member ID
- UHC-90583-09
- Date of birth
- 2001-06-06
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-416572
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-1696
- Coverage period
- 2025-03-01 to present
- Deductible
- $975.65 of $1,500.0065%
- Out-of-pocket maximum
- $2,398.48 of $6,000.0040%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 5701797651
- Network
- Out of network
- Rendering NPI
- 6191696833
- Location
- Nashville, TN · TIN 99-4024660
- Authorisation / referral
- PA2026443237 / REF508926
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 | 99214 | Office visit, established patient, moderate complexity | 59 | 1 | 1 | $252.00 | $113.40 | — | — | DeniedCO204 |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | 59 | 1 | 1 | $1,866.00 | $839.70 | — | — | DeniedCO204 |
| Totals | $2,118.00 | $953.10 | — | — | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- Patient account
- PA-563621
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-006692 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-08: NAVIGATE-HMO (HMO), effective 2025-03-01. | |
| Timely filing | Pass | Received 25 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026443237 on file for 43239. | |
| 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) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Center2026-06-08 17:30
Patient seen for encounter for screening for malignant neoplasm of colon.
- SystemSystem: Claims system2026-07-03 02:46
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-07-03 12:26
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterPA2026443237_approval.pdf2 pages
Utilisation management approval letter for 99214 (Office visit, established patient, moderate complexity), valid 2026-06-08 to 2026-09-06.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 5701797651 is out of network and the HMO plan has no out-of-network benefit. Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009530 | 2026-08-08 | Sunrise Physical Therapy | $280.00 | Needs review |
| CLM-2026-009529 | 2026-08-08 | Lakeside Physical Therapy | $280.00 | Approved |
| CLM-2026-031384 | 2025-12-13 | Lakeside Physical Therapy | $156.00 | 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
No out-of-network benefit on this plan.