CLM-2026-004016
Sunrise Cardiovascular Associates, Cardiology. Service 2026-07-26 at outpatient hospital (POS 22). Received 2026-09-04.
Member
Resolved through the identity graph
- Member
- Mike Simmons
- Member ID
- UHC-55383-31
- Date of birth
- 1994-02-27
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-416736
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-4135
- Coverage period
- 2021-11-01 to present
- Deductible
- $322.47 of $500.0064%
- Out-of-pocket maximum
- $257.96 of $1,000.0026%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4663411393
- Network
- In network
- Rendering NPI
- 6262679908
- Location
- Tampa, FL · TIN 46-7082027
- 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 | 93015 | Cardiovascular stress test | — | 1 | 1 | $356.00 | $195.80 | $179.36 | $16.44 | Paid |
| Totals | $356.00 | $195.80 | $179.36 | $16.44 | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. R07.9 Chest pain, unspecified
- 3. I50.9 Heart failure, unspecified
- Patient account
- PA-755557
- 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-000648 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-26: MEDICARE-ADV-B (MA), effective 2021-11-01. | |
| Timely filing | Pass | Received 40 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 (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 Associates2026-07-26 13:25
Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-755557.pdf7 pages
Itemised statement totalling $356.00 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 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-034283 | 2026-03-05 | Pinecrest Regional Medical Center | $205.00 | Approved |
| CLM-2026-032854 | 2026-02-26 | Desert Internal Medicine Associates | $94.00 | Approved |
| CLM-2026-008390 | 2025-12-12 | Evergreen Diagnostic Imaging | $4,855.00 | 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.