CLM-2026-008071
Sunrise Heart Institute, Cardiology. Service 2026-04-27 at outpatient hospital (POS 22). Received 2026-05-25.
Member
Resolved through the identity graph
- Member
- Kyle Rogers
- Member ID
- UHC-43750-48
- Date of birth
- 1941-02-15
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-416218
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-2942
- Coverage period
- 2021-05-01 to 2026-03-22
- Deductible
- $101.98 of $500.0020%
- Out-of-pocket maximum
- $302.40 of $2,000.0015%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 7885317132
- Network
- In network
- Rendering NPI
- 7016230667
- Location
- Mesa, AZ · TIN 11-9149520
- 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 | $682.00 | $375.10 | — | — | DeniedCO27 |
| Totals | $682.00 | $375.10 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-505676
- 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-027165 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-27 is after coverage terminated on 2026-03-22. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 28 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 Heart Institute (7885317132). | |
| 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 Heart Institute2026-04-27 09:37
Patient seen for unspecified atrial fibrillation.
- SystemSystem: Claims system2026-05-25 00:39
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-05-25 08:05
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-505676.pdf7 pages
Itemised statement totalling $682.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-04-27 is after coverage terminated on 2026-03-22.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031010 | 2026-04-18 | Summit Cardiovascular Associates | $3,193.00 | Denied |
| CLM-2026-003515 | 2026-04-28 | Mesa Clinical Laboratories | $62.00 | Denied |
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.