CLM-2026-014819
Sunrise Internal Medicine Associates, Internal Medicine. Service 2026-03-01 at office (POS 11). Received 2026-03-16.
Member
Resolved through the identity graph
- Member
- Timothy Perry
- Member ID
- UHC-32260-32
- Date of birth
- 2008-05-20
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-419628
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9420
- Coverage period
- 2023-12-01 to present
- Deductible
- $1,720.65 of $2,500.0069%
- Out-of-pocket maximum
- $2,598.31 of $7,500.0035%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 4157086917
- Network
- In network
- Rendering NPI
- 6126971954
- Location
- Los Angeles, CA · TIN 63-0943534
- Authorisation / referral
- none / REF352106
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 | $290.00 | $179.80 | $25.00 | $154.80 | Paid |
| 2 | 80053 | Comprehensive metabolic panel | 25 | 1 | 1 | $71.00 | $44.02 | $0.00 | $44.02 | Paid |
| Totals | $361.00 | $223.82 | $25.00 | $198.82 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-344556
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-020133 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-01: CORE-HMO (HMO), effective 2023-12-01. | |
| Timely filing | Pass | Received 15 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 Internal Medicine Associates (4157086917). | |
| 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 Internal Medicine Associates2026-03-01 11:06
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-026883 | 2026-02-20 | Lakeside Dermatology Clinic | $218.00 | 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.