CLM-2026-011027
Sunrise Digestive Health Center, Gastroenterology. Service 2026-03-31 at outpatient hospital (POS 22). Received 2026-04-29.
Member
Resolved through the identity graph
- Member
- Bruce Dean
- Member ID
- UHC-92761-61
- Date of birth
- 1983-05-07
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-422369
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-7502
- Coverage period
- 2024-01-01 to present
- Deductible
- $754.96 of $1,000.0075%
- Out-of-pocket maximum
- $795.53 of $2,000.0040%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 3482505971
- Network
- In network
- Rendering NPI
- 7563759811
- Location
- Los Angeles, CA · TIN 56-5803475
- Authorisation / referral
- PA2025660242 / 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 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1 | $243.00 | $133.65 | $133.65 | $0.00 | Paid |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | 25 | 1 | 1,2 | $2,237.00 | $1,230.35 | $447.08 | $783.27 | Paid |
| Totals | $2,480.00 | $1,364.00 | $580.73 | $783.27 | ||||||
- 1. R10.13 Epigastric painprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
- Patient account
- PA-686837
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-028300 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-31: OPTIONS-PPO (PPO), effective 2024-01-01. | |
| Timely filing | Pass | Received 29 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025660242 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 | 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 Center2026-03-31 10:29
Established patient presents with epigastric pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025660242_approval.pdf2 pages
Utilisation management approval letter for 88305 (Surgical pathology, level IV), valid 2026-03-31 to 2026-06-29.
- Itemized billitemized_PA-686837.pdf9 pages
Itemised statement totalling $2480.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
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.