CLM-2026-007436
Sunrise Diabetes Center, Endocrinology. Service 2026-04-04 at office (POS 11). Received 2026-04-06.
Member
Resolved through the identity graph
- Member
- Alice Ortiz
- Member ID
- UHC-15710-14
- Date of birth
- 1971-04-13
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-431270
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-4059
- Coverage period
- 2022-02-01 to present
- Deductible
- $1,899.62 of $3,500.0054%
- Out-of-pocket maximum
- $2,465.43 of $7,000.0035%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Diabetes CenterEndocrinology · taxonomy 207RE0101X
- NPI
- 1154539146
- Network
- In network
- Rendering NPI
- 3175051465
- 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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $45.00 | $27.90 | $27.90 | $0.00 | Paid |
| Totals | $45.00 | $27.90 | $27.90 | $0.00 | ||||||
- 1. E05.90 Thyrotoxicosis, unspecifiedprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-212104
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000574 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-04: MEDICARE-ADV-A (MA), effective 2022-02-01. | |
| 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 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 Center2026-04-04 13:29
Patient seen for thyrotoxicosis, unspecified. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-04-06 06:37
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-04-06 13:20
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-212104.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004737 | 2026-06-08 | Meadow Primary Care Associates | $306.00 | Approved |
| CLM-2026-020480 | 2025-12-22 | Unity Imaging Center | $416.00 | Approved |
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
Authorisation must be confirmed with UM before payment.