CLM-2026-020179
Sunrise GI Associates, Gastroenterology. Service 2026-08-12 at office (POS 11). Received 2026-08-18.
Member
Resolved through the identity graph
- Member
- Matthew Day
- Member ID
- UHC-65445-38
- Date of birth
- 1971-04-04
- Identity
- Verified6 records, confidence 0.97
- Claim record
- CLMCLM-408612
- Relationship
- Child, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-4562
- Coverage period
- 2021-11-01 to 2026-01-02
- Deductible
- $1,087.00 of $3,500.0031%
- Out-of-pocket maximum
- $1,109.73 of $10,500.0011%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 3324417310
- Network
- In network
- Rendering NPI
- 5962663691
- Location
- Phoenix, AZ · TIN 97-9024956
- Authorisation / referral
- none / REF639335
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 | $305.00 | $189.10 | — | — | DeniedCO27 |
| Totals | $305.00 | $189.10 | — | — | ||||||
- 1. R10.13 Epigastric painprincipal
- 2. K21.9 Gastro-esophageal reflux disease without esophagitis
- Patient account
- PA-979916
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-001601 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-12 is after coverage terminated on 2026-01-02. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 6 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 GI Associates (3324417310). | |
| 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 GI Associates2026-08-12 18:28
Established patient presents with epigastric pain; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-18 02:18
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-08-18 09:48
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-12 is after coverage terminated on 2026-01-02.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020836 | 2026-09-11 | Desert Medical Group | $568.00 | Denied |
| CLM-2026-016714 | 2026-09-16 | Canyon Primary Care Associates | $452.00 | Denied |
| CLM-2026-013669 | 2026-04-22 | Heritage Digestive Health Center | $263.00 | Denied |
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.