CLM-2026-019695
Sunrise Family Practice, Family Medicine. Service 2026-03-11 at office (POS 11). Received 2026-03-26.
Member
Resolved through the identity graph
- Member
- Olivia Berry
- Member ID
- UHC-49255-57
- Date of birth
- 1987-12-10
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-414408
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group NULL
- Coverage period
- 2022-09-01 to present
- Deductible
- $2,205.54 of $2,500.0088%
- Out-of-pocket maximum
- $992.61 of $5,000.0020%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 3793775529
- Network
- In network
- Rendering NPI
- 6514418915
- Location
- Miami, FL · TIN 77-9706037
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $282.00 | $174.84 | $20.00 | $154.84 | Paid |
| 2 | 99203 | Office visit, new patient, low complexity | 25 | 1 | 1,2 | $208.00 | $128.96 | $0.00 | $128.96 | Paid |
| Totals | $490.00 | $303.80 | $20.00 | $283.80 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- 3. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-312323
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-003732 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-03-11: CORE-HMO (HMO), effective 2022-09-01. | |
| Timely filing | Pass | Received 15 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 Family Practice (3793775529). | |
| 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 Family Practice2026-03-11 10:42
Patient seen for type 2 diabetes mellitus without complications.
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 12:44Clean claim.
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.