CLM-2026-030607
Sunrise GI Associates, Gastroenterology. Service 2025-08-10 at outpatient hospital (POS 22). Received 2026-03-09.
Member
Resolved through the identity graph
- Member
- Natalie Graham
- Member ID
- UHC-06183-55
- Date of birth
- 1969-01-02
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-402094
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-7550
- Coverage period
- 2025-05-01 to present
- Deductible
- $168.64 of $1,500.0011%
- Out-of-pocket maximum
- $521.72 of $3,000.0017%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 3324417310
- Network
- In network
- Rendering NPI
- 2274239393
- Location
- Phoenix, AZ · TIN 97-9024956
- 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 | $219.00 | $120.45 | — | — | DeniedCO29 |
| Totals | $219.00 | $120.45 | — | — | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- 2. R10.13 Epigastric pain
- Patient account
- PA-182939
- 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-003139 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-08-10: NULL (PPO), effective 2025-05-01. | |
| Timely filing | Fail | CO29 | Received 211 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 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 Associates2025-08-10 17:20
Patient seen for encounter for screening for malignant neoplasm of colon.
- SystemSystem: Claims system2026-03-09 00:46
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
- Itemized billitemized_PA-182939.pdf8 pages
Itemised statement totalling $219.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 211 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011752 | 2026-01-07 | Sunrise Cardiovascular Associates | $420.00 | Approved |
| CLM-2026-017865 | 2025-12-21 | Pinecrest Medical Group | $212.00 | Approved |
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.