CLM-2026-025297
Sunrise Digestive Health Center, Gastroenterology. Service 2026-08-11 at outpatient hospital (POS 22). Received 2026-08-31.
Member
Resolved through the identity graph
- Member
- Russell Morales
- Member ID
- none on golden record
- Date of birth
- 1969-02-22
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-404943
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2270
- Coverage period
- 2025-10-01 to 2026-03-19
- Deductible
- $1,725.32 of $2,500.0069%
- Out-of-pocket maximum
- $2,529.22 of $7,500.0034%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 5701797651
- Network
- Out of network
- Rendering NPI
- 4057101162
- Location
- Nashville, TN · TIN 99-4024660
- Authorisation / referral
- PA2025473628 / 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 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1 | $1,524.00 | $685.80 | — | — | DeniedCO27 |
| Totals | $1,524.00 | $685.80 | — | — | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- Patient account
- PA-154090
- 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-003916; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Fail | CO27 | Date of service 2026-08-11 is after coverage terminated on 2026-03-19. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 20 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025473628 on file for 45378. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Digestive Health Center2026-08-11 09:12
Follow-up for encounter for screening for malignant neoplasm of colon. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-31 04:32
Attachments
Documents received with the claim
- Prior auth letterPA2025473628_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-08-11 to 2026-11-09.
- Itemized billitemized_PA-154090.pdf8 pages
Itemised statement totalling $1524.00 across 1 line.
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-003916; payment withheld until the identity is confirmed. Eligibility: Date of service 2026-08-11 is after coverage terminated on 2026-03-19. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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.