CLM-2026-031559
Sunrise Medical Group, Internal Medicine. Service 2026-05-21 at office (POS 11). Received 2026-06-18.
Member
Resolved through the identity graph
- Member
- Carl Duncan
- Member ID
- UHC-95895-02
- Date of birth
- 1971-02-08
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-417539
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-8247
- Coverage period
- 2025-10-01 to present
- Deductible
- $906.62 of $1,500.0060%
- Out-of-pocket maximum
- $1,881.01 of $4,500.0042%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 4023193814
- Network
- In network
- Rendering NPI
- 1228594218
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $60.00 | $37.20 | $20.00 | $17.20 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | 25 | 1 | 1,2 | $290.00 | $179.80 | $0.00 | $179.80 | Paid |
| Totals | $350.00 | $217.00 | $20.00 | $197.00 | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-378788
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-006742 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-21: NULL (PPO), effective 2025-10-01. | |
| Timely filing | Pass | Received 28 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 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Medical Group2026-05-21 14:46
Follow-up for copd, unspecified. Plan discussed, medications reconciled. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-06-18 03:26
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-06-18 16:33
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-378788.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029188 | 2026-01-02 | Pinecrest Regional Medical Center | $156.00 | 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
Authorisation must be confirmed with UM before payment.