CLM-2026-020404
Sunrise Medical Group, Internal Medicine. Service 2025-12-24 at office (POS 11). Received 2026-01-09.
Member
Resolved through the identity graph
- Member
- Ann Welch
- Member ID
- UHC-96949-18
- Date of birth
- 1990-11-23
- Identity
- Verified4 records, confidence 0.98
- Claim record
- CLMCLM-412726
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8573
- Coverage period
- 2025-09-01 to present
- Deductible
- $162.27 of $1,500.0011%
- Out-of-pocket maximum
- $923.37 of $6,000.0015%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 7336268843
- Network
- Out of network
- Rendering NPI
- 8472835122
- Location
- Denver, CO · TIN 30-5353916
- Authorisation / referral
- none / REF154242
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 | $280.00 | $126.00 | — | — | DeniedCO204 |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 1,2 | $395.00 | $177.75 | — | — | DeniedCO204 |
| Totals | $675.00 | $303.75 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-116015
- 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-002728 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2025-12-24: CORE-HMO (HMO), effective 2025-09-01. | |
| Timely filing | Pass | Received 16 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 | Fail | CO204 | Billing provider 7336268843 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Group2025-12-24 10:59
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-01-09 00:02
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 7336268843 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018277 | 2026-03-08 | Summit Digestive Health Center | $1,999.00 | Denied |
| CLM-2026-016602 | 2026-05-11 | Canyon Internal Medicine Associates | $340.00 | Denied |
| CLM-2026-028461 | 2026-04-06 | Meadow Physical Therapy | $190.00 | Approved |
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
No out-of-network benefit on this plan.