CLM-2026-012519
Sunrise Digestive Health Center, Gastroenterology. Service 2026-01-09 at outpatient hospital (POS 22). Received 2026-02-15.
Member
Resolved through the identity graph
- Member
- Patricia Adams
- Member ID
- UHC-55595-27
- Date of birth
- 1963-01-04
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-427307
- Relationship
- Child, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-6476
- Coverage period
- 2021-12-01 to present
- Deductible
- $2,114.58 of $3,500.0060%
- Out-of-pocket maximum
- $6,150.52 of $14,000.0044%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 5701797651
- Network
- Out of network
- Rendering NPI
- 5848767500
- Location
- Nashville, TN · TIN 99-4024660
- Authorisation / referral
- PA2026627577 / REF986990
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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,428.00 | $1,092.60 | — | — | DeniedCO204 |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1 | $1,399.00 | $629.55 | — | — | DeniedCO204 |
| 3 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1 | $1,886.00 | $848.70 | — | — | DeniedCO204 |
| Totals | $5,713.00 | $2,570.85 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-620150
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-013261 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-09: NAVIGATE-HMO (HMO), effective 2021-12-01. | |
| Timely filing | Pass | Received 37 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026627577 on file for 70553, 43239, 45378. | |
| Provider network | Fail | CO204 | Billing provider 5701797651 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| Medical necessity | Review | CO50 | 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity. Not medically necessary per payer policy |
| 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 Center2026-01-09 17:42
Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-02-15 05:12
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
- Prior auth letterPA2026627577_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-01-09 to 2026-04-09.
- Itemized billitemized_PA-620150.pdf6 pages
Itemised statement totalling $5713.00 across 3 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 5701797651 is out of network and the HMO plan has no out-of-network benefit. Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005796 | 2026-06-23 | Valley Primary Care Associates | $474.00 | Approved |
| CLM-2026-032693 | 2026-01-22 | Riverside Medical Group | $462.00 | 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
No out-of-network benefit on this plan.