CLM-2026-009490
Sunrise Digestive Health Center, Gastroenterology. Service 2026-02-26 at outpatient hospital (POS 22). Received 2026-04-01.
Member
Resolved through the identity graph
- Member
- Martha Washington
- Member ID
- UHC-25585-33
- Date of birth
- 2001-09-04
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-428622
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-3464
- Coverage period
- 2025-11-01 to present
- Deductible
- $280.31 of $1,000.0028%
- Out-of-pocket maximum
- $1,046.05 of $4,000.0026%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 5701797651
- Network
- Out of network
- Rendering NPI
- 7932411250
- Location
- Nashville, TN · TIN 99-4024660
- Authorisation / referral
- PA2025617933 / none
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 | $2,472.00 | $1,112.40 | $837.50 | $274.90 | Paid |
| 2 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1 | $256.00 | $115.20 | $34.56 | $80.64 | Paid |
| Totals | $2,728.00 | $1,227.60 | $872.06 | $355.54 | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- Patient account
- PA-472461
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-019322 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-26: - (PPO), effective 2025-11-01. | |
| Timely filing | Pass | Received 34 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025617933 on file for 43239. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Center2026-02-26 15:53
Patient seen for gastro-esophageal reflux disease without esophagitis.
Attachments
Documents received with the claim
- Prior auth letterPA2025617933_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-02-26 to 2026-05-27.
- Itemized billitemized_PA-472461.pdf4 pages
Itemised statement totalling $2728.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021858 | 2026-05-28 | Riverside Primary Care Associates | $302.00 | 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.