Claims workbench/CLM-2026-031633
Professional claim · CMS-1500 · EDI 837P

CLM-2026-031633

Sunrise GI Associates, Gastroenterology. Service 2026-08-30 at office (POS 11). Received 2026-10-10.

PendedIdentity on hold: CASE-003062
Billed
$284.00
1 line
Allowed
$176.08
if approved
Plan pays
—
Pended
Member owes
—
copay / deductible / 10% coinsurance
Rules engine
Pend
IDQ
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Aaron Nunez
Member ID
UHC-75381-08
Date of birth
1987-02-13
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-425617
Relationship
Self, Tucson, AZ

Coverage and accumulators

Found by member ID

Plan
OPTIONS-PPO PPO group GRP-5280
Coverage period
2021-07-01 to present
Deductible
$10.46 of $500.002%
Out-of-pocket maximum
$298.34 of $1,500.0020%
Copays
office $30.00, specialist $40.00, emergency $150.00
Physical therapy visits
16 of 20 used

Provider

Billing and rendering

Billing provider
Sunrise GI Associates
Gastroenterology · taxonomy 207RG0100X
NPI
3324417310
Network
In network
Rendering NPI
1171086444
Location
Phoenix, AZ · TIN 97-9024956
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199214Office visit, established patient, moderate complexity—11$284.00$176.08——PendedIDQ
Totals$284.00$176.08——
Diagnoses (ICD-10-CM)
  • 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
Claim header
Patient account
PA-570128
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

CheckResultCodeDetail
Member identityFailIDQMember record is in open steward case CASE-003062; payment withheld until the identity is confirmed.
Member identity under steward review
EligibilityPassActive on 2026-08-30: OPTIONS-PPO (PPO), effective 2021-07-01.
Timely filingPassReceived 41 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Sunrise GI Associates (3324417310).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Sunrise GI Associates2026-08-30 12:42

    Established patient presents with irritable bowel syndrome with diarrhea; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-21 13:43
    Member identity: Member record is in open steward case CASE-003062; payment withheld until the identity is confirmed.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

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

A hard rule decided this claim; the AI is advisory here.

Examiner decision

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

Outcome
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: Clean

Clean claim, priced at contract rate.

Review queueMember identity