CLM-2026-033093
Sunrise Digestive Health Center, Gastroenterology. Service 2026-09-30 at outpatient hospital (POS 22). Received 2026-10-08.
Member
Resolved through the identity graph
- Member
- Jacob Cooper
- Member ID
- UHC-27394-07
- Date of birth
- 1971-11-28
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-409728
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3206
- Coverage period
- 2022-10-01 to 2026-02-07
- Deductible
- $366.82 of $500.0073%
- Out-of-pocket maximum
- $329.81 of $2,000.0016%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 3482505971
- Network
- In network
- Rendering NPI
- 9793506822
- Location
- Los Angeles, CA · TIN 56-5803475
- 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 | $311.00 | $171.05 | — | — | DeniedCO27 |
| Totals | $311.00 | $171.05 | — | — | ||||||
- 1. R10.13 Epigastric painprincipal
- 2. K21.9 Gastro-esophageal reflux disease without esophagitis
- Patient account
- PA-486188
- 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-038426 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-30 is after coverage terminated on 2026-02-07. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 8 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 Digestive Health Center (3482505971). | |
| 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 Digestive Health Center2026-09-30 14:32
Patient seen for epigastric pain.
- SystemSystem: Claims system2026-10-08 06:48
Attachments
Documents received with the claim
- Itemized billitemized_PA-486188.pdf5 pages
Itemised statement totalling $311.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-09-30 is after coverage terminated on 2026-02-07.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033096 | 2026-06-23 | Heritage Medical Group | $79.00 | Denied |
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
Service after coverage termination.