CLM-2026-033574
Sunrise Digestive Health Center, Gastroenterology. Service 2026-05-16 at outpatient hospital (POS 22). Received 2026-06-15.
Member
Resolved through the identity graph
- Member
- Jordan Rose
- Member ID
- UHC-57654-16
- Date of birth
- 1980-10-09
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-420806
- Relationship
- Spouse, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-1230
- Coverage period
- 2022-03-01 to present
- Deductible
- $427.38 of $1,000.0043%
- Out-of-pocket maximum
- $1,514.15 of $4,000.0038%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 3482505971
- Network
- In network
- Rendering NPI
- 2688515164
- Location
- Los Angeles, CA · TIN 56-5803475
- Authorisation / referral
- PA2025554698 / 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 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1 | $1,609.00 | $884.95 | $635.09 | $249.86 | Paid |
| Totals | $1,609.00 | $884.95 | $635.09 | $249.86 | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
- Patient account
- PA-755712
- 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-010527 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-05-16: SELECT-EPO (EPO), effective 2022-03-01. | |
| Timely filing | Pass | Received 30 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025554698 on file for 43239. | |
| 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 Center2026-05-16 16:18
Patient seen for gastro-esophageal reflux disease without esophagitis.
Attachments
Documents received with the claim
- Prior auth letterPA2025554698_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-05-16 to 2026-08-14.
- Itemized billitemized_PA-755712.pdf2 pages
Itemised statement totalling $1609.00 across 1 line.
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-2026-017078 | 2026-06-18 | Pinecrest Behavioral Health | $644.00 | Approved |
| CLM-2026-015534 | 2026-05-21 | Desert Rehabilitation Center | $279.00 | 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
Clean claim, priced at contract rate.