CLM-2026-005466
Sunrise Heart Institute, Cardiology. Service 2026-02-13 at outpatient hospital (POS 22). Received 2026-03-13.
Member
Resolved through the identity graph
- Member
- Frances Yang
- Member ID
- UHC-53107-97
- Date of birth
- 1968-08-14
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-431683
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-8629
- Coverage period
- 2024-05-01 to present
- Deductible
- $236.66 of $2,500.009%
- Out-of-pocket maximum
- $4,209.50 of $10,000.0042%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 7885317132
- Network
- In network
- Rendering NPI
- 1051292948
- Location
- Mesa, AZ · TIN 11-9149520
- 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 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,354.00 | $744.70 | — | — | DeniedCO197 |
| 2 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1,2 | $8,255.00 | $4,540.25 | — | — | DeniedCO197 |
| Totals | $9,609.00 | $5,284.95 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. I50.9 Heart failure, unspecified
- 3. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-130585
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- 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-002057 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-02-13: NULL (PPO), effective 2024-05-01. | |
| Timely filing | Pass | Received 28 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 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 Institute2026-02-13 10:01
Patient seen for chest pain, unspecified.
- SystemSystem: Claims system2026-03-13 06:31
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-130585.pdf2 pages
Itemised statement totalling $9609.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 93458 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
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.