CLM-2026-010129
Sunrise Digestive Health Center, Gastroenterology. Service 2026-09-26 at office (POS 11). Received 2026-10-08.
Member
Resolved through the identity graph
- Member
- Scott Ward
- Member ID
- UHC-40403-01
- Date of birth
- 1943-10-21
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-414794
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-4024
- Coverage period
- 2025-12-01 to present
- Deductible
- $1,925.69 of $3,500.0055%
- Out-of-pocket maximum
- $1,419.54 of $7,000.0020%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 3482505971
- Network
- In network
- Rendering NPI
- 9763500813
- Location
- Los Angeles, CA · TIN 56-5803475
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $229.00 | $141.98 | — | — | Review |
| Totals | $229.00 | $141.98 | — | — | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
- Patient account
- PA-109207
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-005999 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-09-26: MEDICARE-ADV-A (MA), effective 2025-12-01. | |
| Timely filing | Pass | Received 12 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 Digestive Health Center (3482505971). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Follow-up for encounter for screening for malignant neoplasm of colon. Plan discussed, med”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Digestive Health Center2026-09-26 09:19
Follow-up for encounter for screening for malignant neoplasm of colon. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-10-08 00:26
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Follow-up for encounter for screening for malignant neoplasm of colon. Plan discussed, med”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033256 | 2026-10-01 | Unity Primary Care Associates | $453.00 | Approved |
| CLM-2026-021275 | 2026-09-04 | Valley Skin Care Associates | $179.00 | Approved |
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
Development letter outstanding.