CLM-2026-000436
Sunrise Cardiovascular Associates, Cardiology. Service 2026-08-10 at outpatient hospital (POS 22). Received 2026-09-23.
Member
Resolved through the identity graph
- Member
- Patrick Boyd
- Member ID
- UHC-93836-29
- Date of birth
- 1977-05-24
- Identity
- Verified6 records, confidence 0.93
- Claim record
- CLMCLM-420446
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-2893
- Coverage period
- 2022-11-01 to present
- Deductible
- $559.15 of $1,500.0037%
- Out-of-pocket maximum
- $2,808.13 of $6,000.0047%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 6315639594
- Network
- Out of network
- Rendering NPI
- 7599807204
- Location
- Austin, TX · TIN 17-4007347
- 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 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,313.00 | $590.85 | $590.85 | $0.00 | Paid |
| Totals | $1,313.00 | $590.85 | $590.85 | $0.00 | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- Patient account
- PA-460491
- 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-001790 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-08-10: MEDICARE-ADV-A (MA), effective 2022-11-01. | |
| Timely filing | Pass | Received 44 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Cardiovascular Associates2026-08-10 09:57
Patient seen for heart failure, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-460491.pdf5 pages
Itemised statement totalling $1313.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-000798 | 2026-07-23 | Desert Internal Medicine Associates | $434.00 | Approved |
| CLM-2026-009727 | 2025-12-20 | Valley Clinical Laboratories | $164.00 | 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.