CLM-2026-031658
Sunrise Internal Medicine Associates, Internal Medicine. Service 2026-06-04 to 2026-06-05 at inpatient hospital (POS 21). Received 2026-07-23.
Member
Resolved through the identity graph
- Member
- Kelly Andrews
- Member ID
- UHC-58244-95
- Date of birth
- 1945-12-17
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-424845
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-7815
- Coverage period
- 2024-08-01 to present
- Deductible
- $720.37 of $1,000.0072%
- Out-of-pocket maximum
- $529.98 of $2,000.0026%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 4157086917
- Network
- In network
- Rendering NPI
- 1596598833
- Location
- Los Angeles, CA · TIN 63-0943534
- 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 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $171.00 | $94.05 | — | — | Review |
| Totals | $171.00 | $94.05 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-272731
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-06-04 to 2026-06-06
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-017642 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-04: MEDICARE-ADV-A (MA), effective 2024-08-01. | |
| Timely filing | Pass | Received 48 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-031657, billed by a different provider. Possible duplicate |
| 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 Associates2026-06-05 18:33
Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-07-23 04:12
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
Attachments
Documents received with the claim
- Itemized billitemized_PA-272731.pdf6 pages
Itemised statement totalling $171.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Duplicate check: Same member, date of service and procedures as CLM-2026-031657, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031657 | 2026-06-04 | Pinecrest Medical Group | $171.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Different billing provider; separately payable.