CLM-2026-012086
Sunrise Medical Group, Internal Medicine. Service 2026-07-05 at office (POS 11). Received 2026-07-18.
Member
Resolved through the identity graph
- Member
- Eugene Dixon
- Member ID
- UHC-58673-86
- Date of birth
- 1948-11-18
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-421851
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3607
- Coverage period
- 2023-10-01 to present
- Deductible
- $2,506.40 of $3,500.0072%
- Out-of-pocket maximum
- $4,005.34 of $14,000.0029%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 4023193814
- Network
- In network
- Rendering NPI
- 7076945402
- Location
- Austin, TX · TIN 44-7321338
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $260.00 | $161.20 | — | — | DeniedCO18 |
| Totals | $260.00 | $161.20 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-507883
- 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-033240 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-07-05: CHOICE-PLUS-PPO (PPO), effective 2023-10-01. | |
| Timely filing | Pass | Received 13 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-012085: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Sunrise Medical Group (4023193814). | |
| 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 Medical Group2026-07-05 09:37
Patient seen for chronic kidney disease, stage 3 unspecified.
- SystemSystem: Claims system2026-07-18 06:59
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-07-18 09:18
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-012085: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012085 | 2026-07-05 | Sunrise Medical Group | $260.00 | Approved |
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
Exact duplicate of an earlier submission.