CLM-2026-017463
Sunrise Medical Group, Internal Medicine. Service 2026-06-29 to 2026-07-01 at inpatient hospital (POS 21). Received 2026-07-08.
Member
Resolved through the identity graph
- Member
- Amber Contreras
- Member ID
- UHC-34873-58
- Date of birth
- 1960-03-11
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-425329
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-8598
- Coverage period
- 2021-09-01 to present
- Deductible
- $579.43 of $1,500.0039%
- Out-of-pocket maximum
- $145.60 of $3,000.005%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 4023193814
- Network
- In network
- Rendering NPI
- 7808244108
- Location
- Austin, TX · TIN 44-7321338
- Authorisation / referral
- none / REF862556
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 | $181.00 | $99.55 | $99.55 | $0.00 | Paid |
| Totals | $181.00 | $99.55 | $99.55 | $0.00 | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- 3. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-965913
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-06-29 to 2026-06-30
- 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-037778 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-29: NAVIGATE-HMO (HMO), effective 2021-09-01. | |
| Timely filing | Pass | Received 7 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 Medical Group (4023193814). | |
| 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 Group2026-07-01 18:18
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-965913.pdf9 pages
Itemised statement totalling $181.00 across 1 line.
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001331 | 2026-07-07 | Valley Primary Care Associates | $463.00 | Approved |
| CLM-2026-017464 | 2026-06-29 | Sunrise Medical Group | $181.00 | Denied |
| CLM-2026-016514 | 2026-06-27 | Mesa Internal Medicine Associates | $53.00 | 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.