CLM-2026-021370
Sunrise Diabetes Center, Endocrinology. Service 2026-06-06 at office (POS 11). Received 2026-06-16.
Member
Resolved through the identity graph
- Member
- Amy Carr
- Member ID
- UHC-43150-75
- Date of birth
- 1981-05-24
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-429931
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8029
- Coverage period
- 2022-02-01 to 2026-05-01
- Deductible
- $552.72 of $1,000.0055%
- Out-of-pocket maximum
- $1,038.81 of $3,000.0035%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Diabetes CenterEndocrinology · taxonomy 207RE0101X
- NPI
- 1154539146
- Network
- In network
- Rendering NPI
- 7618381421
- Location
- Tampa, FL · TIN 90-8967175
- 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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $75.00 | $46.50 | — | — | DeniedCO27 |
| 2 | 99214 | Office visit, established patient, moderate complexity | 25 | 1 | 1 | $314.00 | $194.68 | — | — | DeniedCO27 |
| 3 | 99215 | Office visit, established patient, high complexity | 25 | 1 | 2 | $314.00 | $194.68 | — | — | DeniedCO27 |
| Totals | $703.00 | $435.86 | — | — | ||||||
- 1. E05.90 Thyrotoxicosis, unspecifiedprincipal
- Patient account
- PA-490667
- 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-015811 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-06 is after coverage terminated on 2026-05-01. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 10 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 Diabetes Center (1154539146). | |
| 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 Diabetes Center2026-06-06 11:57
Patient seen for thyrotoxicosis, unspecified.
- SystemSystem: Claims system2026-06-16 04:38
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-06-16 10:29
Escalated to nurse reviewer for clinical opinion.
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 2026-06-06 is after coverage terminated on 2026-05-01.
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.