CLM-2026-023933
Sunrise Counseling Center, Behavioral Health. Service 2026-05-06 at outpatient hospital (POS 22). Received 2026-06-09.
Member
Resolved through the identity graph
- Member
- Gibson Pamela
- Member ID
- UHC-70252-36
- Date of birth
- 1956-08-17
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-428973
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3248
- Coverage period
- 2024-03-01 to 2026-03-16
- Deductible
- $1,207.73 of $1,500.0081%
- Out-of-pocket maximum
- $1,543.07 of $4,500.0034%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 6738075996
- Network
- In network
- Rendering NPI
- 4939629554
- Location
- Miami, FL · TIN 80-4501911
- Authorisation / referral
- PA2025718659 / none
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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,624.00 | $1,443.20 | — | — | DeniedCO27 |
| Totals | $2,624.00 | $1,443.20 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-343135
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-024237 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-06 is after coverage terminated on 2026-03-16. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 34 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025718659 on file for 70553. | |
| Provider network | Pass | In-network provider Sunrise Counseling Center (6738075996). | |
| Medical necessity | Review | CO50 | 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity. Not medically necessary per payer policy |
| 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 Counseling Center2026-05-06 16:08
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-09 02:13
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-06-09 08:58
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterPA2025718659_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-05-06 to 2026-08-04.
- Itemized billitemized_PA-343135.pdf4 pages
Itemised statement totalling $2624.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-05-06 is after coverage terminated on 2026-03-16. Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
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.