CLM-2026-015672
Sunrise Medical Group, Internal Medicine. Service 2026-08-28 to 2026-08-29 at inpatient hospital (POS 21). Received 2026-09-15.
Member
Resolved through the identity graph
- Member
- Debra Collins
- Member ID
- UHC-86010-85
- Date of birth
- 1980-11-19
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-406051
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-9288
- Coverage period
- 2023-04-01 to 2026-04-09
- Deductible
- $765.89 of $1,000.0077%
- Out-of-pocket maximum
- $69.63 of $2,000.003%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 7336268843
- Network
- Out of network
- Rendering NPI
- 8470034835
- Location
- Denver, CO · TIN 30-5353916
- Authorisation / referral
- none / REF506813
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 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $235.00 | $105.75 | — | — | DeniedCO27 |
| Totals | $235.00 | $105.75 | — | — | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-365727
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-08-28 to 2026-08-31
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-003252 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-28 is after coverage terminated on 2026-04-09. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 17 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 HMO 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 Group2026-08-29 18:00
Patient seen for copd, unspecified.
- SystemSystem: Claims system2026-09-15 04:57
Attachments
Documents received with the claim
- Itemized billitemized_PA-365727.pdf7 pages
Itemised statement totalling $235.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-28 is after coverage terminated on 2026-04-09. Provider network: Billing provider 7336268843 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
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
Service after coverage termination.