CLM-2026-004067
Sunrise Heart Institute, Cardiology. Service 2026-08-22 at outpatient hospital (POS 22). Received 2026-08-29.
Member
Resolved through the identity graph
- Member
- Jeremy Cook
- Member ID
- UHC-20902-98
- Date of birth
- 1948-08-19
- Identity
- Verified7 records, confidence 0.97
- Claim record
- CLMCLM-410386
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-7088
- Coverage period
- 2022-05-01 to present
- Deductible
- $780.60 of $3,500.0022%
- Out-of-pocket maximum
- $487.90 of $7,000.007%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 7885317132
- Network
- In network
- Rendering NPI
- 7168687946
- Location
- Mesa, AZ · TIN 11-9149520
- Authorisation / referral
- PA2025476933 / REF562343
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 | $6,988.00 | $3,843.40 | $2,944.20 | $899.20 | Paid |
| Totals | $6,988.00 | $3,843.40 | $2,944.20 | $899.20 | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- 3. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-299792
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- 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-012010 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-08-22: CORE-HMO (HMO), effective 2022-05-01. | |
| Timely filing | Pass | Received 7 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025476933 on file for 93458. | |
| Provider network | Pass | In-network provider Sunrise Heart Institute (7885317132). | |
| 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 Heart Institute2026-08-22 17:55
Follow-up for heart failure, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025476933_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-08-22 to 2026-11-20.
- Itemized billitemized_PA-299792.pdf6 pages
Itemised statement totalling $6988.00 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-2026-001759 | 2026-08-09 | Harbor Rehabilitation Center | $128.00 | Approved |
| CLM-2026-029006 | 2026-05-06 | Evergreen Family Practice | $146.00 | Denied |
| CLM-2026-029005 | 2026-05-06 | Evergreen Family Practice | $146.00 | Approved |
| CLM-2026-001428 | 2026-03-19 | Lakeside Physical Therapy | $451.00 | Approved |
| CLM-2026-017941 | 2026-03-12 | Cornerstone Orthopedic Specialists | $247.00 | Denied |
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.