CLM-2026-029334
Sunrise Internal Medicine Associates, Internal Medicine. Service 2026-07-07 to 2026-07-11 at inpatient hospital (POS 21). Received 2026-08-06.
Member
Resolved through the identity graph
- Member
- Nicholas Phillips
- Member ID
- UHC-19239-27
- Date of birth
- 1985-06-03
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-408381
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-2205
- Coverage period
- 2023-06-01 to 2026-01-17
- Deductible
- $663.08 of $1,500.0044%
- Out-of-pocket maximum
- $1,361.23 of $4,500.0030%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 4157086917
- Network
- In network
- Rendering NPI
- 6299521909
- Location
- Los Angeles, CA · TIN 63-0943534
- Authorisation / referral
- none / 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 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $214.00 | $117.70 | — | — | DeniedCO27 |
| Totals | $214.00 | $117.70 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. J44.9 COPD, unspecified
- 3. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-213748
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-07-07 to 2026-07-09
- 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-022010 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-07 is after coverage terminated on 2026-01-17. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 26 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 | Pass | In-network provider Sunrise Internal Medicine Associates (4157086917). | |
| 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 Internal Medicine Associates2026-07-11 15:48
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-06 02:20
Attachments
Documents received with the claim
- Itemized billitemized_PA-213748.pdf4 pages
Itemised statement totalling $214.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-07-07 is after coverage terminated on 2026-01-17.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022998 | 2026-05-20 | Mesa Orthopedic Specialists | $1,247.00 | Denied |
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.