CLM-2026-006497
Sunrise Digestive Health Center, Gastroenterology. Service 2026-02-26 at outpatient hospital (POS 22). Received 2026-03-11.
Member
Resolved through the identity graph
- Member
- Dot Hansen
- Member ID
- UHC-58649-64
- Date of birth
- 1951-06-26
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-430737
- Relationship
- Child, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group -
- Coverage period
- 2022-10-01 to present
- Deductible
- $238.07 of $3,500.007%
- Out-of-pocket maximum
- $1,298.78 of $14,000.009%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 5701797651
- Network
- Out of network
- Rendering NPI
- 6132455364
- Location
- Nashville, TN · TIN 99-4024660
- Authorisation / referral
- PA2026408492 / none
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 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1 | $2,452.00 | $1,103.40 | $1,103.40 | $0.00 | Paid |
| Totals | $2,452.00 | $1,103.40 | $1,103.40 | $0.00 | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
- Patient account
- PA-501200
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-018981 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-26: UNKNOWN (PPO), effective 2022-10-01. | |
| Timely filing | Pass | Received 13 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026408492 on file for 43239. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Center2026-02-26 12:56
Established patient presents with encounter for screening for malignant neoplasm of colon; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026408492_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-02-26 to 2026-05-27.
- Itemized billitemized_PA-501200.pdf5 pages
Itemised statement totalling $2452.00 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 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
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.