CLM-2026-020029
Sunrise Medical Group, Family Medicine. Service 2026-07-22 at office (POS 11). Received 2026-08-26.
Member
Resolved through the identity graph
- Member
- Mei Obrien
- Member ID
- UHC-15488-51
- Date of birth
- 1973-10-21
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-426367
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group GRP-3561
- Coverage period
- 2023-09-01 to 2026-03-17
- Deductible
- $1,250.21 of $1,500.0083%
- Out-of-pocket maximum
- $837.79 of $3,000.0028%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 4611967884
- Network
- In network
- Rendering NPI
- 6253293271
- Location
- Miami, FL · TIN 60-6374313
- 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 | 36415 | Venipuncture | — | 1 | 1 | $22.00 | $13.64 | — | — | DeniedCO27 |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 1,2 | $197.00 | $122.14 | — | — | DeniedCO27 |
| 3 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $237.00 | $146.94 | — | — | DeniedCO27 |
| Totals | $456.00 | $282.72 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-249199
- 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-034935 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-22 is after coverage terminated on 2026-03-17. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 35 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 (4611967884). | |
| 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 Group2026-07-22 14:40
Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-26 01:09
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 2026-07-22 is after coverage terminated on 2026-03-17.
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.