CLM-2026-027632
Sunrise Digestive Health Center, Gastroenterology. Service 2026-06-15 at office (POS 11). Received 2026-06-25.
Member
Resolved through the identity graph
- Member
- Roger Myers
- Member ID
- UHC-73410-29
- Date of birth
- 2003-10-14
- Identity
- Verified3 records, confidence 0.93
- Claim record
- CLMCLM-425272
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-8825
- Coverage period
- 2022-03-01 to 2026-02-01
- Deductible
- $51.38 of $500.0010%
- Out-of-pocket maximum
- $406.73 of $1,500.0027%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 5701797651
- Network
- Out of network
- Rendering NPI
- 1074020292
- Location
- Nashville, TN · TIN 99-4024660
- Authorisation / referral
- none / none
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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $274.00 | $123.30 | — | — | DeniedCO27 |
| Totals | $274.00 | $123.30 | — | — | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- Patient account
- PA-305442
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-014964 (verified, link confidence 0.93). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-15 is after coverage terminated on 2026-02-01. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 10 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 | 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 Center2026-06-15 11:12
Patient seen for irritable bowel syndrome with diarrhea.
- SystemSystem: Claims system2026-06-25 01:05
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-06-25 15:17
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-06-15 is after coverage terminated on 2026-02-01. 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.