CLM-2026-009933
Sunrise Medical Group, Family Medicine. Service 2026-03-04 at office (POS 11). Received 2026-04-07.
Member
Resolved through the identity graph
- Member
- Debra Ramos
- Member ID
- none on golden record
- Date of birth
- 1992-04-19
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-411270
- Relationship
- Child, Minneapolis, MN
Coverage and accumulators
Found by name and date of birth
- Plan
- OPTIONS-PPO PPO group GRP-2670
- Coverage period
- 2025-10-01 to 2026-03-07
- Deductible
- $157.78 of $500.0032%
- Out-of-pocket maximum
- $766.05 of $2,000.0038%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 4611967884
- Network
- In network
- Rendering NPI
- 4438821884
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $211.00 | $130.82 | — | — | PendedIDQ |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $145.00 | $89.90 | — | — | PendedIDQ |
| Totals | $356.00 | $220.72 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-707671
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-003694; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-03-04: OPTIONS-PPO (PPO), effective 2025-10-01, terms 2026-03-07. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 34 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 Group2026-03-04 14:15
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-003694; payment withheld until the identity is confirmed. Eligibility: Active on 2026-03-04: OPTIONS-PPO (PPO), effective 2025-10-01, terms 2026-03-07. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.