CLM-2026-014052
Sunrise Digestive Health Center, Gastroenterology. Service 2026-08-17 at outpatient hospital (POS 22). Received 2026-09-17.
Member
Resolved through the identity graph
- Member
- Rachel Willis
- Member ID
- UHC-19492-19
- Date of birth
- 1975-12-03
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-410927
- Relationship
- Child, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group NULL
- Coverage period
- 2024-03-01 to present
- Deductible
- $837.83 of $2,500.0034%
- Out-of-pocket maximum
- $2,293.74 of $7,500.0031%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 3482505971
- Network
- In network
- Rendering NPI
- 9902197554
- Location
- Los Angeles, CA · TIN 56-5803475
- Authorisation / referral
- none / REF307077
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 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1 | $259.00 | $142.45 | $142.45 | $0.00 | Paid |
| Totals | $259.00 | $142.45 | $142.45 | $0.00 | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- 2. R10.13 Epigastric pain
- Patient account
- PA-517205
- 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-022358 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-17: NAVIGATE-HMO (HMO), effective 2024-03-01. | |
| Timely filing | Pass | Received 31 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 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 Center2026-08-17 09:08
Patient seen for irritable bowel syndrome with diarrhea.
Attachments
Documents received with the claim
- Itemized billitemized_PA-517205.pdf2 pages
Itemised statement totalling $259.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001645 | 2026-02-25 | Unity Cardiovascular Associates | $260.00 | 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.