CLM-2026-027106
Sunrise Digestive Health Center, Gastroenterology. Service 2026-07-05 at outpatient hospital (POS 22). Received 2026-07-31.
Member
Resolved through the identity graph
- Member
- Christopher Webb
- Member ID
- UHC-62698-47
- Date of birth
- 1988-01-17
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-407210
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-0897
- Coverage period
- 2022-01-01 to present
- Deductible
- $438.38 of $1,500.0029%
- Out-of-pocket maximum
- $1,816.03 of $4,500.0040%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 3482505971
- Network
- In network
- Rendering NPI
- 4300690565
- Location
- Los Angeles, CA · TIN 56-5803475
- Authorisation / referral
- PA2025409675 / 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 | 59 | 1 | 1 | $1,497.00 | $823.35 | — | — | Review |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | 59 | 1 | 2 | $2,540.00 | $1,397.00 | — | — | Review |
| Totals | $4,037.00 | $2,220.35 | — | — | ||||||
- 1. R10.13 Epigastric painprincipal
- Patient account
- PA-995367
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-017249 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-05: CHOICE-PLUS-PPO (PPO), effective 2022-01-01. | |
| Timely filing | Pass | Received 26 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025409675 on file for 45378, 43239. | |
| Provider network | Pass | In-network provider Sunrise Digestive Health Center (3482505971). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Center2026-07-05 11:12
Established patient presents with epigastric pain; symptoms reviewed and vitals within expected range. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-07-31 02:23
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-07-31 11:33
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Prior auth letterPA2025409675_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-07-05 to 2026-10-03.
- Itemized billitemized_PA-995367.pdf3 pages
Itemised statement totalling $4037.00 across 2 lines.
- Medical recordrecords_PA-995367.pdf17 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-015625 | 2026-01-23 | Summit Regional Medical Center | $709.00 | 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
Bundled code pair; modifier 59 not supported by the operative note.