CLM-2026-012977
Sunrise Digestive Health Center, Gastroenterology. Service 2026-08-09 at outpatient hospital (POS 22). Received 2026-08-22.
Member
Resolved through the identity graph
- Member
- Wei Schmidt
- Member ID
- UHC-72575-73
- Date of birth
- 1974-03-03
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-404613
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8225
- Coverage period
- 2023-11-01 to present
- Deductible
- $846.96 of $2,500.0034%
- Out-of-pocket maximum
- $867.04 of $5,000.0017%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 3482505971
- Network
- In network
- Rendering NPI
- 4856383466
- Location
- Los Angeles, CA · TIN 56-5803475
- Authorisation / referral
- PA2025064213 / 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 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1 | $2,547.00 | $1,400.85 | $1,400.85 | $0.00 | Paid |
| Totals | $2,547.00 | $1,400.85 | $1,400.85 | $0.00 | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- 2. Z12.11 Encounter for screening for malignant neoplasm of colon
- Patient account
- PA-444975
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-042200 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-09: UNKNOWN (PPO), effective 2023-11-01. | |
| Timely filing | Pass | Received 13 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025064213 on file for 43239. | |
| Provider network | Pass | In-network provider Sunrise Digestive Health Center (3482505971). | |
| 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 Digestive Health Center2026-08-09 11:29
Established patient presents with irritable bowel syndrome with diarrhea; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025064213_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-08-09 to 2026-11-07.
- Itemized billitemized_PA-444975.pdf5 pages
Itemised statement totalling $2547.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
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.