CLM-2026-005639
Sunrise Cardiovascular Associates, Cardiology. Service 2025-12-30 at outpatient hospital (POS 22). Received 2026-02-05.
Member
Resolved through the identity graph
- Member
- Lucia Lewis
- Member ID
- UHC-36306-59
- Date of birth
- 1969-06-11
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-429821
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-3180
- Coverage period
- 2024-01-01 to present
- Deductible
- $874.16 of $1,500.0058%
- Out-of-pocket maximum
- $487.17 of $3,000.0016%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- 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
- 1873831600
- Location
- Tampa, FL · TIN 46-7082027
- Authorisation / referral
- PA2026783360 / 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 | $370.00 | $203.50 | $203.50 | $0.00 | Paid |
| 2 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $8,324.00 | $4,578.20 | $1,669.10 | $2,909.10 | Paid |
| Totals | $8,694.00 | $4,781.70 | $1,872.60 | $2,909.10 | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- Patient account
- PA-233597
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-010507 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-30: NULL (PPO), effective 2024-01-01. | |
| Timely filing | Pass | Received 37 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026783360 on file for 93458. | |
| 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 Associates2025-12-30 13:30
Established patient presents with atherosclerotic heart disease of native coronary artery without angina; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026783360_approval.pdf2 pages
Utilisation management approval letter for 93015 (Cardiovascular stress test), valid 2025-12-30 to 2026-03-30.
- Itemized billitemized_PA-233597.pdf9 pages
Itemised statement totalling $8694.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
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.