CLM-2026-000447
Sunrise Cardiovascular Associates, Cardiology. Service 2026-09-07 at outpatient hospital (POS 22). Received 2026-10-13.
Member
Resolved through the identity graph
- Member
- Austin Robinson
- Member ID
- UHC-83901-95
- Date of birth
- 1955-04-05
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-430240
- Relationship
- Spouse, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6693
- Coverage period
- 2021-07-01 to present
- Deductible
- $535.85 of $1,000.0054%
- Out-of-pocket maximum
- $1,244.42 of $4,000.0031%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 7132857724
- Network
- In network
- Rendering NPI
- 5355217428
- Location
- Charlotte, NC · TIN 50-7613597
- 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 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $5,014.00 | $2,757.70 | — | — | DeniedCO197 |
| Totals | $5,014.00 | $2,757.70 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-868756
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- 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-011360 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-09-07: - (PPO), effective 2021-07-01. | |
| Timely filing | Pass | Received 36 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 93458 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Sunrise Cardiovascular Associates (7132857724). | |
| 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 Associates2026-09-07 14:06
Established patient presents with unspecified atrial fibrillation; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-10-13 05:25
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-10-13 10:06
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-868756.pdf5 pages
Itemised statement totalling $5014.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 93458 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011804 | 2026-05-05 | Pinecrest Diagnostic Imaging | $2,599.00 | Approved |
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
Precertification required and absent.