Professional claim · CMS-1500 · Paper
CLM-2026-014545
Sunrise GI Associates, Gastroenterology. Service 2026-03-03 at office (POS 11). Received 2026-04-15.
Approved
Billed
$276.00
1 line
Allowed
$171.12
contract rate applied
Plan pays
$111.12
approved
Member owes
$60.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Bruce Alexander
- Member ID
- UHC-66040-77
- Date of birth
- 1988-07-25
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-429561
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8479
- Coverage period
- 2023-10-01 to present
- Deductible
- $684.17 of $1,500.0046%
- Out-of-pocket maximum
- $1,598.66 of $4,500.0036%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 3324417310
- Network
- In network
- Rendering NPI
- 5839885568
- Location
- Phoenix, AZ · TIN 97-9024956
- Authorisation / referral
- none / REF343108
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $276.00 | $171.12 | $60.00 | $111.12 | Paid |
| Totals | $276.00 | $171.12 | $60.00 | $111.12 | ||||||
Diagnoses (ICD-10-CM)
- 1. R10.13 Epigastric painprincipal
- 2. Z12.11 Encounter for screening for malignant neoplasm of colon
Claim header
- Patient account
- PA-141898
- 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-025301 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-03: CORE-HMO (HMO), effective 2023-10-01. | |
| Timely filing | Pass | Received 43 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 GI Associates (3324417310). | |
| 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. |
Evaluated 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise GI Associates2026-03-03 10:17
Patient seen for epigastric pain.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$276.00
Plan discount
$104.88
contracted rate
Plan paid
$111.12
You may owe
$60.00
copay, deductible and coinsurance
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-2026-021738 | 2026-06-22 | Unity Digestive Health Center | $2,730.00 | Needs review |
| CLM-2026-019481 | 2026-04-07 | Sunrise Medical Group | $287.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.