CLM-2026-008293
Sunrise Medical Group, Internal Medicine. Service 2026-04-19 at office (POS 11). Received 2026-05-19.
Member
Resolved through the identity graph
- Member
- Santiago Peterson
- Member ID
- UHC-10537-45
- Date of birth
- 1979-11-22
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-424739
- Relationship
- Spouse, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-3522
- Coverage period
- 2025-05-01 to present
- Deductible
- $213.62 of $500.0043%
- Out-of-pocket maximum
- $488.88 of $2,000.0024%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 4023193814
- Network
- In network
- Rendering NPI
- 3163913312
- Location
- Austin, TX · TIN 44-7321338
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $45.00 | $27.90 | $27.90 | $0.00 | Paid |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $391.00 | $242.42 | $0.00 | $242.42 | Paid |
| Totals | $436.00 | $270.32 | $27.90 | $242.42 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-344822
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-022962 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-19: NULL (PPO), effective 2025-05-01. | |
| Timely filing | Pass | Received 30 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 (4023193814). | |
| 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 Group2026-04-19 13:45
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-014333 | 2026-06-13 | Mesa Internal Medicine Associates | $606.00 | Approved |
| CLM-2026-032304 | 2026-06-12 | Summit Internal Medicine Associates | $1,935.00 | Needs review |
| CLM-2026-022032 | 2026-03-05 | Unity Primary Care Associates | $259.00 | 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
Clean claim, priced at contract rate.