CLM-2026-005302
Sunrise Family Practice, Family Medicine. Service 2026-03-13 at office (POS 11). Received 2026-03-15.
Member
Resolved through the identity graph
- Member
- Julia Jackson
- Member ID
- UHC-00538-03
- Date of birth
- 1986-05-03
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-418452
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-0904
- Coverage period
- 2023-09-01 to present
- Deductible
- $635.34 of $2,500.0025%
- Out-of-pocket maximum
- $2,371.08 of $7,500.0032%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 3793775529
- Network
- In network
- Rendering NPI
- 7387577464
- 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 | $270.00 | $167.40 | — | — | Review |
| Totals | $270.00 | $167.40 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-548342
- 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
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-019915 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-03-13: CHOICE-PLUS-PPO (PPO), effective 2023-09-01. | |
| Timely filing | Pass | Received 2 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 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 | Review | CO16 | Documentation incomplete: “Patient seen for type 2 diabetes mellitus without complications. Note dictated; signature ”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Family Practice2026-03-13 16:45
Patient seen for type 2 diabetes mellitus without complications. Note dictated; signature pending.
- SystemSystem: Claims system2026-03-15 05:37
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-03-15 11:56
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Patient seen for type 2 diabetes mellitus without complications. Note dictated; signature ”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016578 | 2026-09-25 | Heritage Internal Medicine Associates | $256.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.