Professional claim · CMS-1500 · EDI 837P
CLM-2026-024718
Sunrise Medical Group, Internal Medicine. Service 2026-02-28 at office (POS 11). Received 2026-03-24.
Billed
$361.00
1 line
Allowed
$162.45
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 20% coinsurance
Rules engine
Deny
CO27, CO204
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Arjun Crawford
- Member ID
- none on golden record
- Date of birth
- 1971-06-23
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-431211
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- NAVIGATE-HMO HMO group GRP-2439
- Coverage period
- 2021-04-01 to 2026-02-27
- Deductible
- $232.70 of $500.0047%
- Out-of-pocket maximum
- $643.31 of $2,000.0032%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 7336268843
- Network
- Out of network
- Rendering NPI
- 7341574318
- Location
- Denver, CO · TIN 30-5353916
- Authorisation / referral
- none / REF477816
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 | $361.00 | $162.45 | — | — | DeniedCO27 |
| Totals | $361.00 | $162.45 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
Claim header
- Patient account
- PA-747021
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-003197; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Fail | CO27 | Date of service 2026-02-28 is after coverage terminated on 2026-02-27. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 24 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Medical Group2026-02-28 16:15
Patient seen for chronic kidney disease, stage 3 unspecified.
- SystemSystem: Claims system2026-03-24 02:59
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-03-24 15:37
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Member identity: Member record is in open steward case CASE-003197; payment withheld until the identity is confirmed. Eligibility: Date of service 2026-02-28 is after coverage terminated on 2026-02-27. Provider 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
No other claims.
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Denied by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
DeniedCO27scenario: Coverage terminated
Service after coverage termination.