CLM-2026-018873
Sunrise Medical Group, Internal Medicine. Service 2026-03-02 at office (POS 11). Received 2026-03-04.
Member
Resolved through the identity graph
- Member
- Mark Carroll
- Member ID
- UHC-63939-24
- Date of birth
- 1980-07-26
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-403958
- Relationship
- Child, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-7851
- Coverage period
- 2025-03-01 to 2026-02-16
- Deductible
- $267.02 of $1,000.0027%
- Out-of-pocket maximum
- $1,758.83 of $4,000.0044%
- Copays
- office $30.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 4023193814
- Network
- In network
- Rendering NPI
- 5482491862
- Location
- Austin, TX · TIN 44-7321338
- 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 | $294.00 | $182.28 | — | — | DeniedCO27 |
| 2 | 99215 | Office visit, established patient, high complexity | 25 | 1 | 1 | $332.00 | $205.84 | — | — | DeniedCO27 |
| 3 | 80053 | Comprehensive metabolic panel | — | 1 | 1,2 | $45.00 | $27.90 | — | — | DeniedCO27 |
| Totals | $671.00 | $416.02 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. J44.9 COPD, unspecified
- Patient account
- PA-140733
- 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-017356 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-03-02 is after coverage terminated on 2026-02-16. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 2 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 Group2026-03-02 13:45
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-03-04 06:20
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-03-04 09:56
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-03-02 is after coverage terminated on 2026-02-16.
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.