CLM-2026-009288
Sunrise Family Practice, Family Medicine. Service 2026-02-11 at office (POS 11). Received 2026-03-01.
Member
Resolved through the identity graph
- Member
- Betty West
- Member ID
- UHC-62994-95
- Date of birth
- 2001-09-13
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-403276
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1203
- Coverage period
- 2021-03-01 to present
- Deductible
- $1,523.04 of $2,500.0061%
- Out-of-pocket maximum
- $2,026.29 of $5,000.0041%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 3793775529
- Network
- In network
- Rendering NPI
- 5036925514
- Location
- Miami, FL · TIN 77-9706037
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $212.00 | $131.44 | $25.00 | $106.44 | Paid |
| Totals | $212.00 | $131.44 | $25.00 | $106.44 | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-418846
- 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-002085 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-11: NULL (PPO), effective 2021-03-01. | |
| Timely filing | Pass | Received 18 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 Family Practice (3793775529). | |
| 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 Family Practice2026-02-11 10:57
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-03-01 00:38
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-03-01 08:49
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-418846.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-2026-018060 | 2026-04-29 | Heritage Medical Group | $579.00 | 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.