Claims workbench/CLM-2026-030532

Professional claim · CMS-1500 · EDI 837P

CLM-2026-030532

Sunrise Medical Group, Internal Medicine. Service 2026-09-11 at office (POS 11). Received 2026-10-21.

Needs reviewReplacement of CLM-2026-030531

Billed

$760.00

3 lines

Allowed

$471.20

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Review

REPL

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Logan James
Member ID: UHC-25785-59
Date of birth: 1945-04-28
Identity: Verified2 records, confidence 1.00
Claim record: CLMCLM-402855
Relationship: Self, Chandler, AZ

Coverage and accumulators

Found by member ID

Plan: SELECT-EPO EPO group GRP-5747
Coverage period: 2025-01-01 to present
Deductible: $38.35 of $2,500.002%
Out-of-pocket maximum: $478.68 of $5,000.0010%
Copays: office $20.00, specialist $60.00, emergency $250.00
Physical therapy visits: 15 of 20 used

Provider

Billing and rendering

Billing provider: Sunrise Medical Group
Internal Medicine · taxonomy 207R00000X
NPI: 4023193814
Network: In network
Rendering NPI: 2771078658
Location: Austin, TX · TIN 44-7321338
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	99214	Office visit, established patient, moderate complexity	—	1	1	$269.00	$166.78	—	—	Review
2	99215	Office visit, established patient, high complexity	—	1	1	$416.00	$257.92	—	—	Review
3	80053	Comprehensive metabolic panel	—	1	1	$75.00	$46.50	—	—	Review
Totals						$760.00	$471.20	—	—

Diagnoses (ICD-10-CM)

1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
2. N18.30 Chronic kidney disease, stage 3 unspecified
3. J44.9 COPD, unspecified

Claim header

Patient account: PA-187260
Frequency code: 7 (replacement)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 12 checks, 1 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-023313 (verified, link confidence 1.00).
Eligibility	Pass		Active on 2026-09-11: SELECT-EPO (EPO), effective 2025-01-01.
Timely filing	Pass		Received 40 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Replacement claim	Review	REPL	Frequency code 7 replaces CLM-2026-030531; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission
Prior authorisation	Pass		No line requires precertification.
Provider network	Pass		In-network provider Sunrise Medical Group (4023193814).
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.

Evaluated 2026-10-21 13:43 under policy version 1. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Sunrise Medical Group2026-09-11 12:59
Follow-up for type 2 diabetes mellitus with hyperglycemia. Plan discussed, medications reconciled. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
SystemSystem: Claims system2026-10-21 03:42
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-10-21 17:37
Escalated to nurse reviewer for clinical opinion.

Attachments

Documents received with the claim

Corrected claimcorrected_CLM-2026-030531.pdf1 page
Provider cover letter requesting replacement of CLM-2026-030531.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Replacement claim: Frequency code 7 replaces CLM-2026-030531; the original must be voided when this adjudicates.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-030531	2026-09-11	Sunrise Medical Group	$760.00	Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

The rules engine left this claim for review. The AI adjudicator can read the evidence pack (lines, notes, attachments, coverage, history) and recommend an outcome with citations.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

Approvedscenario: Replacement

Replacement claim supersedes the original.

Review queue Member identity