CLM-2026-003036
Sunrise Cardiovascular Associates, Cardiology. Service 2026-06-02 at office (POS 11). Received 2026-07-01.
Member
Resolved through the identity graph
- Member
- Yuki King
- Member ID
- UHC-91956-26
- Date of birth
- 1991-07-06
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-412229
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-2756
- Coverage period
- 2024-09-01 to present
- Deductible
- $881.04 of $1,500.0059%
- Out-of-pocket maximum
- $1,349.03 of $4,500.0030%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4904880653
- Network
- In network
- Rendering NPI
- 2987082965
- Location
- Charlotte, NC · TIN 94-7029927
- Authorisation / referral
- none / REF506771
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 | 93224 | Holter monitor, 48 hours | — | 1 | 1 | $417.00 | $258.54 | $60.00 | $198.54 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $235.00 | $145.70 | $0.00 | $145.70 | Paid |
| Totals | $652.00 | $404.24 | $60.00 | $344.24 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-619547
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-002132 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-02: CORE-HMO (HMO), effective 2024-09-01. | |
| Timely filing | Pass | Received 29 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Sunrise Cardiovascular Associates (4904880653). | |
| 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 Associates2026-06-02 11:36
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-07-01 01:01
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-07-01 13:56
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-619547.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030294 | 2025-12-09 | Sunrise Behavioral Health | $230.00 | 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
Authorisation must be confirmed with UM before payment.