CLM-2026-014651
Sunrise Medical Group, Internal Medicine. Service 2025-12-02 at office (POS 11). Received 2026-01-03.
Member
Resolved through the identity graph
- Member
- Brenda Hoffman
- Member ID
- UHC-56523-95
- Date of birth
- 1938-12-27
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-401781
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-3160
- Coverage period
- 2024-08-01 to present
- Deductible
- $204.06 of $1,000.0020%
- Out-of-pocket maximum
- $266.95 of $3,000.009%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 7336268843
- Network
- Out of network
- Rendering NPI
- 6502450979
- Location
- Denver, CO · TIN 30-5353916
- Authorisation / referral
- none / none
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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $59.00 | $26.55 | — | — | DeniedCO204 |
| 2 | 99215 | Office visit, established patient, high complexity | 25 | 1 | 2 | $414.00 | $186.30 | — | — | DeniedCO204 |
| Totals | $473.00 | $212.85 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- Patient account
- PA-932794
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000853 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-12-02: SELECT-EPO (EPO), effective 2024-08-01. | |
| Timely filing | Pass | Received 32 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 | Fail | CO204 | Billing provider 7336268843 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Group2025-12-02 14:33
Established patient presents with type 2 diabetes mellitus with hyperglycemia; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-01-03 01:57
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-01-03 09:49
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 7336268843 is out of network and the EPO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011488 | 2026-05-13 | Sunrise Community Hospital | $184.00 | 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
No out-of-network benefit on this plan.