CLM-2026-000701
Sunrise Cardiovascular Associates, Cardiology. Service 2026-05-06 at outpatient hospital (POS 22). Received 2026-06-04.
Member
Resolved through the identity graph
- Member
- Jonathan Le
- Member ID
- UHC-34946-14
- Date of birth
- 1978-08-09
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-419120
- Relationship
- Spouse, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-3406
- Coverage period
- 2022-06-01 to present
- Deductible
- $131.42 of $1,500.009%
- Out-of-pocket maximum
- $1,856.37 of $6,000.0031%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 9679150778
- Network
- Out of network
- Rendering NPI
- 5307211503
- Location
- Phoenix, AZ · TIN 56-6230971
- Authorisation / referral
- PA2026661271 / 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 | 93015 | Cardiovascular stress test | — | 1 | 1 | $641.00 | $288.45 | $288.45 | $0.00 | Paid |
| 2 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $8,400.00 | $3,780.00 | $1,620.10 | $2,159.90 | Paid |
| 3 | 93306 rev 0480 | Echocardiogram, complete | 25 | 1 | 1 | $1,569.00 | $706.05 | $141.21 | $564.84 | Paid |
| Totals | $10,610.00 | $4,774.50 | $2,049.76 | $2,724.74 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-298903
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-028568 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-05-06: MEDICARE-ADV-B (MA), effective 2022-06-01. | |
| Timely filing | Pass | Received 29 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026661271 on file for 93458. | |
| 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 Associates2026-05-06 12:47
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026661271_approval.pdf2 pages
Utilisation management approval letter for 93015 (Cardiovascular stress test), valid 2026-05-06 to 2026-08-04.
- Itemized billitemized_PA-298903.pdf5 pages
Itemised statement totalling $10610.00 across 3 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider 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-2026-029141 | 2026-05-14 | Unity Cardiovascular Associates | $271.00 | 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.