CLM-2026-014683
Sunrise GI Associates, Gastroenterology. Service 2026-02-12 at outpatient hospital (POS 22). Received 2026-02-20.
Member
Resolved through the identity graph
- Member
- Michelle Soto
- Member ID
- UHC-71794-95
- Date of birth
- 1948-06-18
- Identity
- Verified2 records, confidence 0.94
- Claim record
- CLMCLM-427227
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-8018
- Coverage period
- 2022-12-01 to present
- Deductible
- $2,638.27 of $3,500.0075%
- Out-of-pocket maximum
- $4,571.41 of $14,000.0033%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 3324417310
- Network
- In network
- Rendering NPI
- 2406322596
- Location
- Phoenix, AZ · TIN 97-9024956
- Authorisation / referral
- PA2025493206 / 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 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1 | $342.00 | $188.10 | $188.10 | $0.00 | Paid |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1 | $2,591.00 | $1,425.05 | $823.91 | $601.14 | Paid |
| 3 | 45378 rev 0750 | Colonoscopy, diagnostic | 25 | 1 | 1 | $2,120.00 | $1,166.00 | $233.20 | $932.80 | Paid |
| Totals | $5,053.00 | $2,779.15 | $1,245.21 | $1,533.94 | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- Patient account
- PA-193360
- 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-014640 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2026-02-12: NAVIGATE-HMO (HMO), effective 2022-12-01. | |
| Timely filing | Pass | Received 8 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025493206 on file for 43239, 45378. | |
| 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise GI Associates2026-02-12 09:39
Established patient presents with gastro-esophageal reflux disease without esophagitis; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025493206_approval.pdf2 pages
Utilisation management approval letter for 88305 (Surgical pathology, level IV), valid 2026-02-12 to 2026-05-13.
- Itemized billitemized_PA-193360.pdf7 pages
Itemised statement totalling $5053.00 across 3 lines.
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
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.