CLM-2026-007992
Sunrise Cardiovascular Associates, Cardiology. Service 2026-06-22 at outpatient hospital (POS 22). Received 2026-07-05.
Member
Resolved through the identity graph
- Member
- Virginia Weaver
- Member ID
- UHC-01304-13
- Date of birth
- 1955-09-24
- Identity
- Verified3 records, confidence 0.90
- Claim record
- CLMCLM-419619
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1049
- Coverage period
- 2025-05-01 to present
- Deductible
- $178.80 of $1,000.0018%
- Out-of-pocket maximum
- $1,232.75 of $3,000.0041%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 9679150778
- Network
- Out of network
- Rendering NPI
- 9657440407
- Location
- Phoenix, AZ · TIN 56-6230971
- Authorisation / referral
- PA2025187706 / 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 | $7,351.00 | $3,307.95 | $1,318.55 | $1,989.40 | Paid |
| 2 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 2 | $1,082.00 | $486.90 | $97.38 | $389.52 | Paid |
| Totals | $8,433.00 | $3,794.85 | $1,415.93 | $2,378.92 | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- Patient account
- PA-732983
- 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-000696 (verified, link confidence 0.90). | |
| Eligibility | Pass | Active on 2026-06-22: UNKNOWN (PPO), effective 2025-05-01. | |
| Timely filing | Pass | Received 13 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025187706 on file for 93458. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Associates2026-06-22 10:10
Follow-up for atherosclerotic heart disease of native coronary artery without angina. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025187706_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-06-22 to 2026-09-20.
- Itemized billitemized_PA-732983.pdf5 pages
Itemised statement totalling $8433.00 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 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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.