CLM-2026-005924
Sunrise Diabetes Center, Endocrinology. Service 2026-09-04 at office (POS 11). Received 2026-10-12.
Member
Resolved through the identity graph
- Member
- Heather Lopez
- Member ID
- UHC-55811-29
- Date of birth
- 1941-12-08
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-400949
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-8353
- Coverage period
- 2023-07-01 to 2026-06-14
- Deductible
- $826.94 of $3,500.0024%
- Out-of-pocket maximum
- $2,821.67 of $7,000.0040%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Diabetes CenterEndocrinology · taxonomy 207RE0101X
- NPI
- 1154539146
- Network
- In network
- Rendering NPI
- 4770924387
- Location
- Tampa, FL · TIN 90-8967175
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $296.00 | $183.52 | — | — | DeniedCO27 |
| Totals | $296.00 | $183.52 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E05.90 Thyrotoxicosis, unspecified
- Patient account
- PA-414327
- 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-033403 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-04 is after coverage terminated on 2026-06-14. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 38 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 Diabetes Center (1154539146). | |
| 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 Diabetes Center2026-09-04 09:20
Established patient presents with type 2 diabetes mellitus without complications; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-10-12 00:37
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-10-12 10:53
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-09-04 is after coverage terminated on 2026-06-14.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030139 | 2026-08-14 | Pinecrest Diagnostic Imaging | $2,246.00 | Denied |
| CLM-2026-034368 | 2026-05-09 | Evergreen Counseling Center | $610.00 | 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
Service after coverage termination.