CLM-2026-011186
Sunrise Digestive Health Center, Gastroenterology. Service 2025-10-27 at outpatient hospital (POS 22). Received 2026-05-21.
Member
Resolved through the identity graph
- Member
- Andrew McDonald
- Member ID
- UHC-38489-91
- Date of birth
- 2000-08-21
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-410288
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-6366
- Coverage period
- 2023-01-01 to present
- Deductible
- $3,099.12 of $3,500.0089%
- Out-of-pocket maximum
- $554.87 of $14,000.004%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 3482505971
- Network
- In network
- Rendering NPI
- 6780816610
- Location
- Los Angeles, CA · TIN 56-5803475
- Authorisation / referral
- PA2026471553 / 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 | $2,189.00 | $1,203.95 | — | — | DeniedCO29 |
| Totals | $2,189.00 | $1,203.95 | — | — | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- Patient account
- PA-588692
- 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-031609 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2025-10-27: MEDICARE-ADV-A (MA), effective 2023-01-01. | |
| Timely filing | Fail | CO29 | Received 206 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026471553 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 Center2025-10-27 12:02
Patient seen for gastro-esophageal reflux disease without esophagitis.
- SystemSystem: Claims system2026-05-21 03:31
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
- Prior auth letterPA2026471553_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2025-10-27 to 2026-01-25.
- Itemized billitemized_PA-588692.pdf2 pages
Itemised statement totalling $2189.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 206 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Received after the timely-filing limit.