CLM-2026-005013
Sunrise Cardiovascular Associates, Cardiology. Service 2026-08-21 at outpatient hospital (POS 22). Received 2026-09-20.
Member
Resolved through the identity graph
- Member
- Shirley Gilbert
- Member ID
- UHC-05399-64
- Date of birth
- 1982-10-02
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-421602
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-6955
- Coverage period
- 2023-12-01 to present
- Deductible
- $444.93 of $500.0089%
- Out-of-pocket maximum
- $290.08 of $2,000.0015%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4663411393
- Network
- In network
- Rendering NPI
- 8545482316
- 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 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $4,964.00 | $2,730.20 | — | — | DeniedCO197 |
| Totals | $4,964.00 | $2,730.20 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. I25.10 Atherosclerotic heart disease of native coronary artery without angina
- 3. I50.9 Heart failure, unspecified
- Patient account
- PA-516471
- 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-006765 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-21: SELECT-EPO (EPO), effective 2023-12-01. | |
| Timely filing | Pass | Received 30 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 93458 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| 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 Associates2026-08-21 14:54
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-20 01:09
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
Attachments
Documents received with the claim
- Itemized billitemized_PA-516471.pdf6 pages
Itemised statement totalling $4964.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 93458 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005421 | 2026-07-30 | Meadow Primary Care Associates | $486.00 | Approved |
| CLM-2026-017423 | 2026-01-06 | Heritage Primary Care Associates | $276.00 | Approved |
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
Precertification required and absent.