CLM-2026-006708
Sunrise Medical Group, Family Medicine. Service 2026-08-26 at office (POS 11). Received 2026-08-28.
Member
Resolved through the identity graph
- Member
- Gabriel Luna
- Member ID
- UHC-01468-90
- Date of birth
- 1959-09-13
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-413991
- Relationship
- Spouse, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8793
- Coverage period
- 2025-11-01 to 2026-08-07
- Deductible
- $572.45 of $1,000.0057%
- Out-of-pocket maximum
- $457.95 of $2,000.0023%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 4611967884
- Network
- In network
- Rendering NPI
- 3393233424
- Location
- Miami, FL · TIN 60-6374313
- 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 | $274.00 | $169.88 | — | — | DeniedCO27 |
| Totals | $274.00 | $169.88 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- 3. I10 Essential (primary) hypertension
- Patient account
- PA-772069
- 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-021725 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-26 is after coverage terminated on 2026-08-07. Expenses incurred after coverage terminated |
| 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 Medical Group (4611967884). | |
| 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 Medical Group2026-08-26 14:05
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-28 04:01
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-08-28 12:57
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 engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-26 is after coverage terminated on 2026-08-07.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019125 | 2026-02-27 | Cornerstone Internal Medicine Associates | $422.00 | 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.