CLM-2026-024078
Sunrise Internal Medicine Associates, Internal Medicine. Service 2026-02-07 at office (POS 11). Received 2026-03-06.
Member
Resolved through the identity graph
- Member
- Megan Bradley
- Member ID
- UHC-27109-52
- Date of birth
- 1967-01-09
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-408967
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-7818
- Coverage period
- 2025-09-01 to present
- Deductible
- $69.09 of $1,000.007%
- Out-of-pocket maximum
- $422.30 of $2,000.0021%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 4157086917
- Network
- In network
- Rendering NPI
- 5744063715
- Location
- Los Angeles, CA · TIN 63-0943534
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $373.00 | $231.26 | — | — | Review |
| 2 | 93000 | Electrocardiogram with interpretation | 25 | 1 | 1 | $81.00 | $50.22 | — | — | Review |
| Totals | $454.00 | $281.48 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-363752
- 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-001625 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-07: MEDICARE-ADV-A (MA), effective 2025-09-01. | |
| Timely filing | Pass | Received 27 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 (4157086917). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Established patient presents with type 2 diabetes mellitus with hyperglycemia; symptoms re”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Internal Medicine Associates2026-02-07 11:16
Established patient presents with type 2 diabetes mellitus with hyperglycemia; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-03-06 03:19
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-03-06 09:08
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 engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Established patient presents with type 2 diabetes mellitus with hyperglycemia; symptoms re”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007016 | 2026-07-09 | Sunrise Diagnostic Imaging | $325.00 | Approved |
| CLM-2026-024761 | 2026-05-21 | Canyon Diagnostic Imaging | $420.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.