CLM-2026-032964
Sunrise Medical Group, Family Medicine. Service 2026-08-16 at office (POS 11). Received 2026-09-10.
Member
Resolved through the identity graph
- Member
- Anna Dixon
- Member ID
- UHC-96020-28
- Date of birth
- 1967-09-20
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-402431
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-5853
- Coverage period
- 2025-08-01 to present
- Deductible
- $216.33 of $1,500.0014%
- Out-of-pocket maximum
- $1,324.80 of $4,500.0029%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 7750705916
- Network
- In network
- Rendering NPI
- 2872365855
- Location
- Tampa, FL · TIN 44-4657025
- 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 | 90471 | Immunization administration | — | 1 | 1 | $40.00 | $24.80 | — | — | Review |
| 2 | 36415 | Venipuncture | 25 | 1 | 2 | $21.00 | $13.02 | — | — | Review |
| 3 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $267.00 | $165.54 | — | — | Review |
| Totals | $328.00 | $203.36 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- 3. M54.50 Low back pain, unspecified
- Patient account
- PA-690217
- 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
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-035013 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-16: OPTIONS-PPO (PPO), effective 2025-08-01. | |
| Timely filing | Pass | Received 25 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 (7750705916). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Established patient presents with essential (primary) hypertension; symptoms reviewed and ”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Medical Group2026-08-16 18:57
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-09-10 06:23
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-09-10 16:25
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Established patient presents with essential (primary) hypertension; symptoms reviewed and ”.
Other claims for this member
Same resolved identity
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
Development letter outstanding.