CLM-2026-029013
Sunrise GI Associates, Gastroenterology. Service 2026-07-26 at outpatient hospital (POS 22). Received 2026-08-06.
Member
Resolved through the identity graph
- Member
- Pat Guzman
- Member ID
- UHC-51894-06
- Date of birth
- 1984-06-18
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-432562
- Relationship
- Spouse, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-0536
- Coverage period
- 2025-08-01 to 2026-07-14
- Deductible
- $26.90 of $1,500.002%
- Out-of-pocket maximum
- $595.55 of $3,000.0020%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 3324417310
- Network
- In network
- Rendering NPI
- 6681021427
- Location
- Phoenix, AZ · TIN 97-9024956
- Authorisation / referral
- PA2025063656 / 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 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1 | $2,206.00 | $1,213.30 | — | — | DeniedCO27 |
| Totals | $2,206.00 | $1,213.30 | — | — | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- 2. K21.9 Gastro-esophageal reflux disease without esophagitis
- Patient account
- PA-778219
- 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-020894 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-26 is after coverage terminated on 2026-07-14. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 11 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025063656 on file for 43239. | |
| Provider network | Pass | In-network provider Sunrise GI Associates (3324417310). | |
| 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 GI Associates2026-07-26 10:46
Patient seen for encounter for screening for malignant neoplasm of colon.
- SystemSystem: Claims system2026-08-06 06:21
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-08-06 15:45
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterPA2025063656_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-07-26 to 2026-10-24.
- Itemized billitemized_PA-778219.pdf7 pages
Itemised statement totalling $2206.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-07-26 is after coverage terminated on 2026-07-14.
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.