CLM-2026-014907
Sunrise Medical Group, Internal Medicine. Service 2026-01-26 at office (POS 11). Received 2026-02-04.
Member
Resolved through the identity graph
- Member
- Valentina Marquez
- Member ID
- UHC-01154-91
- Date of birth
- 1979-09-06
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-411483
- Relationship
- Spouse, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-3298
- Coverage period
- 2024-07-01 to present
- Deductible
- $858.36 of $1,500.0057%
- Out-of-pocket maximum
- $484.53 of $3,000.0016%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 7336268843
- Network
- Out of network
- Rendering NPI
- 5131391133
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $230.00 | $103.50 | $30.00 | $73.50 | Paid |
| 2 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $105.00 | $47.25 | $0.00 | $47.25 | Paid |
| Totals | $335.00 | $150.75 | $30.00 | $120.75 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-163113
- 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-002553 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-26: MEDICARE-ADV-A (MA), effective 2024-07-01. | |
| Timely filing | Pass | Received 9 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Group2026-01-26 09:34
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 engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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.