CLM-2026-026554
Sunrise Digestive Health Center, Gastroenterology. Service 2026-04-12 at outpatient hospital (POS 22). Received 2026-04-27.
Member
Resolved through the identity graph
- Member
- Adam Vega
- Member ID
- UHC-59055-13
- Date of birth
- 1992-02-01
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-425768
- Relationship
- Spouse, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3911
- Coverage period
- 2024-03-01 to present
- Deductible
- $158.59 of $2,500.006%
- Out-of-pocket maximum
- $1,385.71 of $10,000.0014%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 3482505971
- Network
- In network
- Rendering NPI
- 4074291632
- Location
- Los Angeles, CA · TIN 56-5803475
- Authorisation / referral
- PA2026538559 / 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 | $2,144.00 | $1,179.20 | — | — | Review |
| 2 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1 | $266.00 | $146.30 | — | — | Review |
| 3 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1,2 | $2,549.00 | $1,401.95 | — | — | Review |
| Totals | $4,959.00 | $2,727.45 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
- Patient account
- PA-447931
- 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-027921 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-12: OPTIONS-PPO (PPO), effective 2024-03-01. | |
| Timely filing | Pass | Received 15 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026538559 on file for 70553, 45378. | |
| Provider network | Pass | In-network provider Sunrise Digestive Health Center (3482505971). | |
| 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 Digestive Health Center2026-04-12 18:44
Patient seen for encounter for general adult medical examination without abnormal findings. Imaging was ordered because of progressive neurological symptoms and failed conservative therapy over 8 weeks; study is medically necessary to rule out structural cause.
- SystemSystem: Claims system2026-04-27 06:50
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-04-27 08:17
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Prior auth letterPA2026538559_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-04-12 to 2026-07-11.
- Itemized billitemized_PA-447931.pdf3 pages
Itemised statement totalling $4959.00 across 3 lines.
- Medical recordrecords_PA-447931.pdf10 pages
Clinic notes documenting 8 weeks of failed conservative therapy and progressive symptoms.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023742 | 2026-09-16 | Summit Regional Medical Center | $2,954.00 | Needs review |
| CLM-2026-005712 | 2026-08-06 | Desert Clinical Laboratories | $194.00 | Denied |
| CLM-2026-005711 | 2026-08-06 | Desert Clinical Laboratories | $194.00 | Approved |
| CLM-2026-000009 | 2026-07-27 | Lakeside Physical Therapy | $266.00 | Approved |
| CLM-2026-017511 | 2026-05-08 | Mesa Medical Group | $223.00 | 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
Notes document medical necessity.