CLM-2026-018483
Sunrise Digestive Health Center, Gastroenterology. Service 2026-08-27 at outpatient hospital (POS 22). Received 2026-09-17.
Member
Resolved through the identity graph
- Member
- Roger Le
- Member ID
- UHC-84334-48
- Date of birth
- 1987-12-14
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-425300
- Relationship
- Spouse, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2144
- Coverage period
- 2025-12-01 to present
- Deductible
- $1,057.18 of $1,500.0070%
- Out-of-pocket maximum
- $2,732.45 of $6,000.0046%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 3482505971
- Network
- In network
- Rendering NPI
- 5651492287
- Location
- Los Angeles, CA · TIN 56-5803475
- Authorisation / referral
- PA2025533623 / 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 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1 | $2,374.00 | $1,305.70 | $701.68 | $604.02 | Paid |
| Totals | $2,374.00 | $1,305.70 | $701.68 | $604.02 | ||||||
- 1. R10.13 Epigastric painprincipal
- Patient account
- PA-323797
- 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-002984 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-27: CHOICE-PLUS-PPO (PPO), effective 2025-12-01. | |
| Timely filing | Pass | Received 21 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025533623 on file for 45378. | |
| Provider network | Pass | In-network provider Sunrise Digestive Health Center (3482505971). | |
| 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 Digestive Health Center2026-08-27 09:36
Established patient presents with epigastric pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025533623_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-08-27 to 2026-11-25.
- Itemized billitemized_PA-323797.pdf3 pages
Itemised statement totalling $2374.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-000336 | 2026-06-05 | Sunrise Cardiovascular Associates | $434.00 | Needs review |
| CLM-2026-028119 | 2026-02-13 | Mesa Clinical Laboratories | $39.00 | Approved |
| CLM-2026-015738 | 2026-03-08 | Mesa Family Practice | $337.00 | 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.