CLM-2026-033989
Sunrise Medical Group, Internal Medicine. Service 2026-08-27 at office (POS 11). Received 2026-10-11.
Member
Resolved through the identity graph
- Member
- Diana Phillips
- Member ID
- UHC-60258-47
- Date of birth
- 1969-12-16
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-419489
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7225
- Coverage period
- 2022-04-01 to present
- Deductible
- $604.98 of $1,000.0060%
- Out-of-pocket maximum
- $265.92 of $2,000.0013%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 7336268843
- Network
- Out of network
- Rendering NPI
- 6801629380
- Location
- Denver, CO · TIN 30-5353916
- Authorisation / referral
- none / REF936007
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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $253.00 | $113.85 | — | — | DeniedCO204 |
| 2 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $61.00 | $27.45 | — | — | DeniedCO204 |
| 3 | 99215 | Office visit, established patient, high complexity | — | 1 | 2 | $401.00 | $180.45 | — | — | DeniedCO204 |
| Totals | $715.00 | $321.75 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. J44.9 COPD, unspecified
- Patient account
- PA-527992
- 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-046274 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-27: NAVIGATE-HMO (HMO), effective 2022-04-01. | |
| Timely filing | Pass | Received 45 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 | Fail | CO204 | Billing provider 7336268843 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Medical Group2026-08-27 16:49
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-10-11 00:19
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 7336268843 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
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
No out-of-network benefit on this plan.