CLM-2026-004599
Sunrise Heart Institute, Cardiology. Service 2026-05-11 at outpatient hospital (POS 22). Received 2026-06-08.
Member
Resolved through the identity graph
- Member
- Elijah Weber
- Member ID
- UHC-76995-58
- Date of birth
- 1993-09-16
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-411579
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- - PPO group UNKNOWN
- Coverage period
- 2024-12-01 to 2026-04-20
- Deductible
- $348.19 of $500.0070%
- Out-of-pocket maximum
- $285.87 of $1,500.0019%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 7885317132
- Network
- In network
- Rendering NPI
- 6064288999
- Location
- Mesa, AZ · TIN 11-9149520
- Authorisation / referral
- PA2026383237 / 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 | $5,350.00 | $2,942.50 | — | — | DeniedCO27 |
| Totals | $5,350.00 | $2,942.50 | — | — | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-335368
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- 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-021488 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-11 is after coverage terminated on 2026-04-20. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 28 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026383237 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 Institute2026-05-11 16:14
Established patient presents with heart failure, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-08 00:21
Attachments
Documents received with the claim
- Prior auth letterPA2026383237_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-05-11 to 2026-08-09.
- Itemized billitemized_PA-335368.pdf5 pages
Itemised statement totalling $5350.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-05-11 is after coverage terminated on 2026-04-20.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-015810 | 2026-05-18 | Mesa Medical Group | $240.00 | Denied |
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
Service after coverage termination.