CLM-2026-010836
Sunrise Digestive Health Center, Gastroenterology. Service 2026-08-30 at outpatient hospital (POS 22). Received 2026-09-23.
Member
Resolved through the identity graph
- Member
- Gary Kelly
- Member ID
- UHC-44852-79
- Date of birth
- 1969-12-25
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-425810
- Relationship
- Child, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7586
- Coverage period
- 2025-06-01 to present
- Deductible
- $47.65 of $1,500.003%
- Out-of-pocket maximum
- $2,119.10 of $6,000.0035%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 3482505971
- Network
- In network
- Rendering NPI
- 1264575667
- Location
- Los Angeles, CA · TIN 56-5803475
- Authorisation / referral
- PA2026609918 / 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 | $2,296.00 | $1,262.80 | — | — | Review |
| Totals | $2,296.00 | $1,262.80 | — | — | ||||||
- 1. R10.13 Epigastric painprincipal
- Patient account
- PA-298499
- 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-022582 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-30: NULL (PPO), effective 2025-06-01. | |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026609918 on file for 43239. | |
| 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: “Established patient presents with epigastric pain; symptoms reviewed and vitals within exp”. 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 Center2026-08-30 18:38
Established patient presents with epigastric pain; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-09-23 02:08
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-09-23 17:35
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Prior auth letterPA2026609918_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-08-30 to 2026-11-28.
- Itemized billitemized_PA-298499.pdf9 pages
Itemised statement totalling $2296.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Established patient presents with epigastric pain; symptoms reviewed and vitals within exp”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029106 | 2026-07-22 | Canyon Diagnostic Imaging | $3,529.00 | Approved |
| CLM-2026-016502 | 2026-02-14 | Evergreen Medical Group | $2,341.00 | Needs review |
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.