CLM-2026-006360
Sunrise Cardiovascular Associates, Cardiology. Service 2026-09-12 at outpatient hospital (POS 22). Received 2026-10-12.
Member
Resolved through the identity graph
- Member
- Joe Matthews
- Member ID
- UHC-80322-37
- Date of birth
- 1945-05-09
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-408500
- Relationship
- Spouse, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1415
- Coverage period
- 2021-10-01 to present
- Deductible
- $160.86 of $500.0032%
- Out-of-pocket maximum
- $736.59 of $1,500.0049%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4663411393
- Network
- In network
- Rendering NPI
- 1137181693
- 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 | 93015 | Cardiovascular stress test | — | 1 | 1 | $472.00 | $259.60 | $259.60 | $0.00 | Paid |
| 2 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 2 | $1,155.00 | $635.25 | $135.11 | $500.14 | Paid |
| Totals | $1,627.00 | $894.85 | $394.71 | $500.14 | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-780583
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-019349 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-12: CHOICE-PLUS-PPO (PPO), effective 2021-10-01. | |
| Timely filing | Pass | Received 30 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| 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 Associates2026-09-12 13:07
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-780583.pdf9 pages
Itemised statement totalling $1627.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025351 | 2026-06-26 | Sunrise Medical Group | $28.00 | Approved |
| CLM-2026-020354 | 2026-05-05 | Unity Primary Care Associates | $566.00 | Needs review |
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.