CLM-2026-029933
Sunrise Internal Medicine Associates, Internal Medicine. Service 2025-11-18 at office (POS 11). Received 2026-05-19.
Member
Resolved through the identity graph
- Member
- Eric McDonald
- Member ID
- UHC-79133-62
- Date of birth
- 2006-08-23
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-419850
- Relationship
- Child, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6984
- Coverage period
- 2025-06-01 to present
- Deductible
- $418.60 of $500.0084%
- Out-of-pocket maximum
- $724.27 of $1,500.0048%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 4157086917
- Network
- In network
- Rendering NPI
- 2161377876
- Location
- Los Angeles, CA · TIN 63-0943534
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $379.00 | $234.98 | — | — | DeniedCO29 |
| 2 | 93000 | Electrocardiogram with interpretation | — | 1 | 1,2 | $98.00 | $60.76 | — | — | DeniedCO29 |
| 3 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $236.00 | $146.32 | — | — | DeniedCO29 |
| Totals | $713.00 | $442.06 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-438851
- 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-020521 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-11-18: CHOICE-PLUS-PPO (PPO), effective 2025-06-01. | |
| Timely filing | Fail | CO29 | Received 182 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Associates2025-11-18 16:11
Established patient presents with chronic kidney disease, stage 3 unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-05-19 04:17
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 182 days after the last date of service (limit 90).
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
Received after the timely-filing limit.