CLM-2026-005658
Sunrise Cardiovascular Associates, Cardiology. Service 2026-03-09 at outpatient hospital (POS 22). Received 2026-04-10.
Member
Resolved through the identity graph
- Member
- Shirley Murary
- Member ID
- UHC-65277-11
- Date of birth
- 1962-02-06
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-428001
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-8669
- Coverage period
- 2021-01-01 to present
- Deductible
- $362.44 of $500.0072%
- Out-of-pocket maximum
- $700.66 of $2,000.0035%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 6315639594
- Network
- Out of network
- Rendering NPI
- 4983907914
- Location
- Austin, TX · TIN 17-4007347
- Authorisation / referral
- PA2026741747 / REF592515
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 | $1,487.00 | $669.15 | — | — | DeniedCO204 |
| 2 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 2 | $5,672.00 | $2,552.40 | — | — | DeniedCO204 |
| Totals | $7,159.00 | $3,221.55 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-302323
- 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-024998 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-09: NAVIGATE-HMO (HMO), effective 2021-01-01. | |
| Timely filing | Pass | Received 32 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026741747 on file for 93458. | |
| Provider network | Fail | CO204 | Billing provider 6315639594 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Associates2026-03-09 17:04
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-04-10 02:09
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-04-10 17:31
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterPA2026741747_approval.pdf2 pages
Utilisation management approval letter for 93306 (Echocardiogram, complete), valid 2026-03-09 to 2026-06-07.
- Itemized billitemized_PA-302323.pdf2 pages
Itemised statement totalling $7159.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 6315639594 is out of network and the HMO plan has no out-of-network benefit.
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
No out-of-network benefit on this plan.