Professional claim · CMS-1500 · EDI 837P
CLM-2026-011277
Sunrise Medical Group, Internal Medicine. Service 2026-03-07 at office (POS 11). Received 2026-04-14.
ApprovedOut of network
Billed
$685.00
3 lines
Allowed
$308.25
contract rate applied
Plan pays
$288.25
approved
Member owes
$20.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Donna Austin
- Member ID
- UHC-08695-42
- Date of birth
- 1956-02-08
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-414945
- Relationship
- Spouse, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2673
- Coverage period
- 2023-12-01 to present
- Deductible
- $381.41 of $2,500.0015%
- Out-of-pocket maximum
- $2,046.79 of $10,000.0020%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 7336268843
- Network
- Out of network
- Rendering NPI
- 6851769227
- Location
- Denver, CO · TIN 30-5353916
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $63.00 | $28.35 | $20.00 | $8.35 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $214.00 | $96.30 | $0.00 | $96.30 | Paid |
| 3 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $408.00 | $183.60 | $0.00 | $183.60 | Paid |
| Totals | $685.00 | $308.25 | $20.00 | $288.25 | ||||||
Diagnoses (ICD-10-CM)
- 1. J44.9 COPD, unspecifiedprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
- 3. I48.91 Unspecified atrial fibrillation
Claim header
- Patient account
- PA-761212
- 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-014710 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-07: CHOICE-PLUS-PPO (PPO), effective 2023-12-01. | |
| Timely filing | Pass | Received 38 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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. |
Evaluated 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Medical Group2026-03-07 09:29
Established patient presents with copd, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$685.00
Plan discount
$376.75
out-of-network allowance
Plan paid
$288.25
You may owe
$20.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-013344 | 2026-08-12 | Heritage Imaging Center | $2,324.00 | Approved |
| CLM-2026-027808 | 2026-02-26 | Pinecrest Bone and Joint Center | $48,898.00 | Denied |
| CLM-2026-027807 | 2026-02-26 | Pinecrest Bone and Joint Center | $48,898.00 | Needs review |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.