CLM-2026-027617
Sunrise Digestive Health Center, Gastroenterology. Service 2026-03-27 at outpatient hospital (POS 22). Received 2026-04-14.
Member
Resolved through the identity graph
- Member
- Brittany Rios
- Member ID
- UHC-10619-92
- Date of birth
- 1946-01-13
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-418468
- Relationship
- Spouse, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-7484
- Coverage period
- 2025-01-01 to present
- Deductible
- $230.86 of $1,000.0023%
- Out-of-pocket maximum
- $656.96 of $4,000.0016%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 5701797651
- Network
- Out of network
- Rendering NPI
- 3110129954
- Location
- Nashville, TN · TIN 99-4024660
- Authorisation / referral
- PA2026192418 / 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 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1 | $252.00 | $113.40 | $113.40 | $0.00 | Paid |
| 2 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 2 | $1,558.00 | $701.10 | $660.28 | $40.82 | Paid |
| Totals | $1,810.00 | $814.50 | $773.68 | $40.82 | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- Patient account
- PA-195421
- 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-017130 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-03-27: MEDICARE-ADV-B (MA), effective 2025-01-01. | |
| Timely filing | Pass | Received 18 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026192418 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 Center2026-03-27 13:30
Patient seen for irritable bowel syndrome with diarrhea.
Attachments
Documents received with the claim
- Prior auth letterPA2026192418_approval.pdf2 pages
Utilisation management approval letter for 88305 (Surgical pathology, level IV), valid 2026-03-27 to 2026-06-25.
- Itemized billitemized_PA-195421.pdf8 pages
Itemised statement totalling $1810.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018096 | 2026-03-23 | Summit Regional Medical Center | $3,929.00 | Denied |
| CLM-2026-030881 | 2026-04-08 | Lakeside Medical Group | $28.00 | Approved |
| CLM-2026-018095 | 2026-03-23 | Summit Regional Medical Center | $3,929.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.