CLM-2026-011611
Sunrise Internal Medicine Associates, Internal Medicine. Service 2026-02-11 at office (POS 11). Received 2026-06-20.
Member
Resolved through the identity graph
- Member
- Tyler Oliver
- Member ID
- UHC-80744-56
- Date of birth
- 1988-04-04
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-407904
- Relationship
- Child, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2537
- Coverage period
- 2022-02-01 to 2026-07-16
- Deductible
- $1,237.82 of $3,500.0035%
- Out-of-pocket maximum
- $4,064.81 of $10,500.0039%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 2528104724
- Network
- In network
- Rendering NPI
- 4129013197
- Location
- Miami, FL · TIN 99-8220672
- 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 | $75.00 | $46.50 | — | — | DeniedCO29 |
| Totals | $75.00 | $46.50 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
- 3. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-863911
- 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-010291 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-11: N/A (PPO), effective 2022-02-01, terms 2026-07-16. | |
| Timely filing | Fail | CO29 | Received 129 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 | No line requires precertification. | |
| Provider network | Pass | In-network provider Sunrise Internal Medicine Associates (2528104724). | |
| 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 Internal Medicine Associates2026-02-11 15:52
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-20 02:37
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
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 129 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.