CLM-2026-029397
Sunrise Digestive Health Center, Gastroenterology. Service 2026-05-16 at outpatient hospital (POS 22). Received 2026-06-29.
Member
Resolved through the identity graph
- Member
- Christian Nguyen
- Member ID
- UHC-03910-55
- Date of birth
- 1978-12-13
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-417387
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3900
- Coverage period
- 2022-12-01 to present
- Deductible
- $2,626.16 of $3,500.0075%
- Out-of-pocket maximum
- $847.35 of $14,000.006%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 5701797651
- Network
- Out of network
- Rendering NPI
- 9238249525
- Location
- Nashville, TN · TIN 99-4024660
- 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 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1 | $237.00 | $106.65 | $106.65 | $0.00 | Paid |
| Totals | $237.00 | $106.65 | $106.65 | $0.00 | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
- Patient account
- PA-154090
- 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-030897 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-16: UNKNOWN (PPO), effective 2022-12-01. | |
| Timely filing | Pass | Received 44 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 Center2026-05-16 09:46
Established patient presents with encounter for screening for malignant neoplasm of colon; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-154090.pdf8 pages
Itemised statement totalling $237.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider 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-2026-000453 | 2026-06-03 | Heritage Primary Care Associates | $22.00 | Approved |
| CLM-2026-008575 | 2026-06-08 | Mesa Clinical Laboratories | $73.00 | Approved |
| CLM-2026-021538 | 2026-04-20 | Lakeside Internal Medicine Associates | $369.00 | 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.