CLM-2026-012810
Sunrise Internal Medicine Associates, Internal Medicine. Service 2025-12-11 to 2025-12-14 at inpatient hospital (POS 21). Received 2026-01-08.
Member
Resolved through the identity graph
- Member
- Patricia Le
- Member ID
- UHC-15651-83
- Date of birth
- 1963-01-08
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-400960
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-7313
- Coverage period
- 2024-10-01 to present
- Deductible
- $475.29 of $2,500.0019%
- Out-of-pocket maximum
- $2,310.70 of $7,500.0031%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 4157086917
- Network
- In network
- Rendering NPI
- 5707099292
- Location
- Los Angeles, CA · TIN 63-0943534
- Authorisation / referral
- none / 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 | 99232 rev 0110 | Subsequent hospital care | 59 | 1 | 1 | $213.00 | $117.15 | — | — | Review |
| 2 | 99215 | Office visit, established patient, high complexity | 59 | 1 | 1,2 | $290.00 | $159.50 | — | — | Review |
| Totals | $503.00 | $276.65 | — | — | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-302034
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2025-12-11 to 2025-12-13
- 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-002487 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-11: OPTIONS-PPO (PPO), effective 2024-10-01. | |
| Timely filing | Pass | Received 25 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 | Pass | In-network provider Sunrise Internal Medicine Associates (4157086917). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Associates2025-12-14 17:25
Established patient presents with copd, unspecified; symptoms reviewed and vitals within expected range. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-01-08 02:58
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Itemized billitemized_PA-302034.pdf9 pages
Itemised statement totalling $503.00 across 2 lines.
- Medical recordrecords_PA-302034.pdf9 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
- AI recommendationDenied2026-10-21 14:15The claim uses modifier 59 on a code pair that is normally bundled (99232 and 99215). The clinical note [N1] confirms that both procedures were performed at the same site during the same session as part of one service, which contradicts the use of modifier 59. According to NCCI edits [R-ncci], this is not allowable, and the claim is denied with reason code CO97.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:15 · 331ac761
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018005 | 2026-09-26 | Riverside Orthopedic Specialists | $46,395.00 | Needs review |
| CLM-2026-019088 | 2026-03-27 | Sunrise Community Hospital | $1,654.00 | Approved |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
- CO97 Benefit included in another service already adjudicated
The claim uses modifier 59 on a code pair that is normally bundled (99232 and 99215). The clinical note [N1] confirms that both procedures were performed at the same site during the same session as part of one service, which contradicts the use of modifier 59. According to NCCI edits [R-ncci], this is not allowable, and the claim is denied with reason code CO97.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
- CO97 Benefit included in another service already adjudicated
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Bundled code pair; modifier 59 not supported by the operative note.