CLM-2026-028869
Sunrise Family Practice, Family Medicine. Service 2026-01-18 at office (POS 11). Received 2026-03-10.
Member
Resolved through the identity graph
- Member
- Samantha Burton
- Member ID
- UHC-13043-98
- Date of birth
- 1966-06-09
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-431209
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-3028
- Coverage period
- 2025-08-01 to present
- Deductible
- $304.92 of $1,500.0020%
- Out-of-pocket maximum
- $2,182.16 of $6,000.0036%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 3793775529
- Network
- In network
- Rendering NPI
- 1615939497
- Location
- Miami, FL · TIN 77-9706037
- 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 | 36415 | Venipuncture | — | 1 | 1 | $22.00 | $13.64 | — | — | DeniedCO18 |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $176.00 | $109.12 | — | — | DeniedCO18 |
| Totals | $198.00 | $122.76 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-508923
- 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-012931 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-18: MEDICARE-ADV-B (MA), effective 2025-08-01. | |
| Timely filing | Pass | Received 51 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-028868: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Sunrise Family Practice (3793775529). | |
| 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 Family Practice2026-01-18 17:46
Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-03-10 00:27
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-03-10 16:19
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 13:43Duplicate check: Exact duplicate of CLM-2026-028868: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017541 | 2026-07-14 | Unity Primary Care Associates | $22.00 | Approved |
| CLM-2026-028868 | 2026-01-18 | Sunrise Family Practice | $198.00 | Approved |
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
Exact duplicate of an earlier submission.