CLM-2026-008490
Sunrise Cardiovascular Associates, Cardiology. Service 2025-12-28 at outpatient hospital (POS 22). Received 2026-01-20.
Member
Resolved through the identity graph
- Member
- Bobby Chapman
- Member ID
- UHC-80403-78
- Date of birth
- 2004-02-20
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-421322
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-7770
- Coverage period
- 2021-11-01 to present
- Deductible
- $907.42 of $3,500.0026%
- Out-of-pocket maximum
- $2,125.84 of $10,500.0020%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 6315639594
- Network
- Out of network
- Rendering NPI
- 5007577682
- Location
- Austin, TX · TIN 17-4007347
- 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 | $532.00 | $239.40 | $239.40 | $0.00 | Paid |
| 2 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,057.00 | $475.65 | $475.65 | $0.00 | Paid |
| Totals | $1,589.00 | $715.05 | $715.05 | $0.00 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-905837
- 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-005944 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-28: OPTIONS-PPO (PPO), effective 2021-11-01. | |
| Timely filing | Pass | Received 23 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 | 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 Associates2025-12-28 16:54
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-905837.pdf3 pages
Itemised statement totalling $1589.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005182 | 2026-05-16 | Riverside Orthopedic Specialists | $29,148.00 | Needs review |
| CLM-2026-020135 | 2025-12-27 | Cornerstone Diabetes Center | $421.00 | Approved |
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.