CLM-2026-012413
Sunrise GI Associates, Gastroenterology. Service 2026-07-04 at outpatient hospital (POS 22). Received 2026-07-22.
Member
Resolved through the identity graph
- Member
- Nathan Campbell
- Member ID
- UHC-33373-43
- Date of birth
- 1985-11-19
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-430099
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-4604
- Coverage period
- 2024-02-01 to present
- Deductible
- $1,287.47 of $3,500.0037%
- Out-of-pocket maximum
- $3,360.42 of $10,500.0032%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 3324417310
- Network
- In network
- Rendering NPI
- 8677222555
- Location
- Phoenix, AZ · TIN 97-9024956
- Authorisation / referral
- PA2025933794 / 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 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1 | $1,966.00 | $1,081.30 | $1,081.30 | $0.00 | Paid |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1 | $1,304.00 | $717.20 | $717.20 | $0.00 | Paid |
| Totals | $3,270.00 | $1,798.50 | $1,798.50 | $0.00 | ||||||
- 1. R10.13 Epigastric painprincipal
- Patient account
- PA-700772
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-003100 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-04: NULL (PPO), effective 2024-02-01. | |
| Timely filing | Pass | Received 18 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025933794 on file for 45378, 43239. | |
| Provider network | Pass | In-network provider Sunrise GI Associates (3324417310). | |
| 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 GI Associates2026-07-04 15:53
Follow-up for epigastric pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025933794_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-07-04 to 2026-10-02.
- Itemized billitemized_PA-700772.pdf6 pages
Itemised statement totalling $3270.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031052 | 2026-10-04 | Unity Bone and Joint Center | $1,994.00 | Approved |
| CLM-2026-022303 | 2026-05-19 | Unity Counseling Center | $221.00 | Approved |
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.