CLM-2026-020830
Sunrise Internal Medicine Associates, Internal Medicine. Service 2026-06-21 to 2026-06-22 at inpatient hospital (POS 21). Received 2026-08-05.
Member
Resolved through the identity graph
- Member
- Stephen Murray
- Member ID
- UHC-92761-01
- Date of birth
- 1962-05-26
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-432797
- Relationship
- Spouse, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5620
- Coverage period
- 2022-10-01 to 2026-02-11
- Deductible
- $1,076.81 of $1,500.0072%
- Out-of-pocket maximum
- $2,096.84 of $4,500.0047%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 2528104724
- Network
- In network
- Rendering NPI
- 3646263798
- Location
- Miami, FL · TIN 99-8220672
- Authorisation / referral
- none / REF587719
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $238.00 | $130.90 | — | — | DeniedCO27 |
| Totals | $238.00 | $130.90 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- 3. J44.9 COPD, unspecified
- Patient account
- PA-967155
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-06-21 to 2026-06-22
- 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-012594 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-21 is after coverage terminated on 2026-02-11. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 44 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 Internal Medicine Associates (2528104724). | |
| 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 Internal Medicine Associates2026-06-22 18:46
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-05 01:50
Attachments
Documents received with the claim
- Itemized billitemized_PA-967155.pdf8 pages
Itemised statement totalling $238.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-06-21 is after coverage terminated on 2026-02-11.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001997 | 2026-08-19 | Pinecrest Bone and Joint Center | $162.00 | Denied |
| CLM-2026-006907 | 2026-07-13 | Valley Imaging Center | $4,713.00 | Denied |
| CLM-2026-029607 | 2026-05-24 | Sunrise Counseling Center | $585.00 | Denied |
| CLM-2026-008987 | 2026-01-26 | Mesa Internal Medicine Associates | $44.00 | 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
Service after coverage termination.