CLM-2026-007090
Sunrise Cardiovascular Associates, Cardiology. Service 2026-08-20 at outpatient hospital (POS 22). Received 2026-10-01.
Member
Resolved through the identity graph
- Member
- Brenda Turner
- Member ID
- UHC-44384-04
- Date of birth
- 1983-08-03
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-409755
- Relationship
- Spouse, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8011
- Coverage period
- 2023-07-01 to 2026-01-14
- Deductible
- $71.40 of $1,000.007%
- Out-of-pocket maximum
- $226.72 of $3,000.008%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4663411393
- Network
- In network
- Rendering NPI
- 7753761536
- Location
- Tampa, FL · TIN 46-7082027
- Authorisation / referral
- PA2025119095 / 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 | $6,974.00 | $3,835.70 | — | — | DeniedCO27 |
| Totals | $6,974.00 | $3,835.70 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-967306
- 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-033910 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-20 is after coverage terminated on 2026-01-14. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 42 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025119095 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 Associates2026-08-20 11:03
Patient seen for unspecified atrial fibrillation.
- SystemSystem: Claims system2026-10-01 01:47
Attachments
Documents received with the claim
- Prior auth letterPA2025119095_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-08-20 to 2026-11-18.
- Itemized billitemized_PA-967306.pdf7 pages
Itemised statement totalling $6974.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-20 is after coverage terminated on 2026-01-14.
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
Service after coverage termination.