CLM-2026-010938
Sunrise Diabetes Center, Endocrinology. Service 2026-03-17 at office (POS 11). Received 2026-03-28.
Member
Resolved through the identity graph
- Member
- Ray Scott
- Member ID
- UHC-74464-51
- Date of birth
- 1988-07-05
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-402118
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-6057
- Coverage period
- 2024-10-01 to present
- Deductible
- $632.28 of $1,500.0042%
- Out-of-pocket maximum
- $1,004.63 of $4,500.0022%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Diabetes CenterEndocrinology · taxonomy 207RE0101X
- NPI
- 1154539146
- Network
- In network
- Rendering NPI
- 4783114992
- Location
- Tampa, FL · TIN 90-8967175
- 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 | 95251 | Continuous glucose monitoring, analysis | — | 1 | 1 | $235.00 | $145.70 | — | — | Review |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $399.00 | $247.38 | — | — | Review |
| Totals | $634.00 | $393.08 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-618174
- 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-012286 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-17: MEDICARE-ADV-A (MA), effective 2024-10-01. | |
| Timely filing | Pass | Received 11 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 Diabetes Center (1154539146). | |
| 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: “Patient seen for type 2 diabetes mellitus without complications. Note dictated; signature ”. 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 Diabetes Center2026-03-17 09:42
Patient seen for type 2 diabetes mellitus without complications. Note dictated; signature pending.
- SystemSystem: Claims system2026-03-28 01:03
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-03-28 13:45
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Completeness: Documentation incomplete: “Patient seen for type 2 diabetes mellitus without complications. Note dictated; signature ”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010963 | 2026-05-23 | Pinecrest Bone and Joint Center | $10,059.00 | Approved |
| CLM-2026-020120 | 2026-02-04 | Sunrise Medical Group | $238.00 | 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.