CLM-2026-013911
Sunrise Medical Group, Internal Medicine. Service 2025-11-17 to 2025-11-21 at inpatient hospital (POS 21). Received 2026-05-20.
Member
Resolved through the identity graph
- Member
- Jacqueline Ryan
- Member ID
- UHC-97443-27
- Date of birth
- 1973-08-14
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-406117
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-4623
- Coverage period
- 2023-08-01 to present
- Deductible
- $84.91 of $500.0017%
- Out-of-pocket maximum
- $454.16 of $2,000.0023%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 7336268843
- Network
- Out of network
- Rendering NPI
- 7283266212
- Location
- Denver, CO · TIN 30-5353916
- 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 | — | 1 | 1 | $203.00 | $91.35 | — | — | DeniedCO29 |
| Totals | $203.00 | $91.35 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. J44.9 COPD, unspecified
- Patient account
- PA-112622
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2025-11-17 to 2025-11-21
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-005979 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-11-17: MEDICARE-ADV-A (MA), effective 2023-08-01. | |
| Timely filing | Fail | CO29 | Received 180 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Group2025-11-21 13:11
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-05-20 06:52
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-05-20 17:48
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-112622.pdf2 pages
Itemised statement totalling $203.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 180 days after the last date of service (limit 90). Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020191 | 2026-03-24 | Sunrise Dermatology Clinic | $187.00 | Approved |
| CLM-2026-017375 | 2025-12-26 | Desert Diagnostic Imaging | $182.00 | 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
Received after the timely-filing limit.