CLM-2026-006554
Sunrise Digestive Health Center, Gastroenterology. Service 2026-10-12 at outpatient hospital (POS 22). Received 2026-10-18.
Member
Resolved through the identity graph
- Member
- Doris Alvarez
- Member ID
- UHC-77452-71
- Date of birth
- 1986-09-11
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-412374
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-7517
- Coverage period
- 2024-03-01 to present
- Deductible
- $785.54 of $1,000.0079%
- Out-of-pocket maximum
- $169.32 of $2,000.008%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 5701797651
- Network
- Out of network
- Rendering NPI
- 5018755962
- Location
- Nashville, TN · TIN 99-4024660
- Authorisation / referral
- PA2025393662 / REF969075
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 | $1,892.00 | $851.40 | — | — | DeniedCO204 |
| 2 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 2 | $260.00 | $117.00 | — | — | DeniedCO204 |
| Totals | $2,152.00 | $968.40 | — | — | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- 2. Z12.11 Encounter for screening for malignant neoplasm of colon
- Patient account
- PA-570271
- 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-040928 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-10-12: CORE-HMO (HMO), effective 2024-03-01. | |
| Timely filing | Pass | Received 6 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025393662 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) | 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 Center2026-10-12 10:08
Established patient presents with irritable bowel syndrome with diarrhea; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-10-18 02:14
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
- Prior auth letterPA2025393662_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-10-12 to 2027-01-10.
- Itemized billitemized_PA-570271.pdf7 pages
Itemised statement totalling $2152.00 across 2 lines.
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.
Other claims for this member
Same resolved identity
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.