CLM-2026-002809
Sunrise Cardiovascular Associates, Cardiology. Service 2026-05-27 at outpatient hospital (POS 22). Received 2026-10-18.
Member
Resolved through the identity graph
- Member
- Olivia Armstrong
- Member ID
- UHC-25797-48
- Date of birth
- 1995-09-11
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-419926
- Relationship
- Spouse, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4969
- Coverage period
- 2025-12-01 to present
- Deductible
- $172.94 of $500.0035%
- Out-of-pocket maximum
- $173.23 of $1,000.0017%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4663411393
- Network
- In network
- Rendering NPI
- 8413449918
- Location
- Tampa, FL · TIN 46-7082027
- Authorisation / referral
- PA2026087610 / 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 | $5,132.00 | $2,822.60 | — | — | DeniedCO29 |
| 2 | 93015 | Cardiovascular stress test | — | 1 | 1,2 | $395.00 | $217.25 | — | — | DeniedCO29 |
| Totals | $5,527.00 | $3,039.85 | — | — | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-900520
- 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-015188 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-27: N/A (PPO), effective 2025-12-01. | |
| Timely filing | Fail | CO29 | Received 144 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026087610 on file for 93458. | |
| Provider network | Pass | In-network provider Sunrise Cardiovascular Associates (4663411393). | |
| 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 Associates2026-05-27 16:29
Established patient presents with heart failure, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-10-18 06:51
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-10-18 12:50
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterPA2026087610_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-05-27 to 2026-08-25.
- Itemized billitemized_PA-900520.pdf8 pages
Itemised statement totalling $5527.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 144 days after the last date of service (limit 90).
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
Received after the timely-filing limit.