CLM-2026-008495
Sunrise Cardiovascular Associates, Cardiology. Service 2026-09-02 at office (POS 11). Received 2026-10-03.
Member
Resolved through the identity graph
- Member
- Jonathan Aguilar
- Member ID
- UHC-85529-50
- Date of birth
- 1951-05-10
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-418840
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-6611
- Coverage period
- 2021-04-01 to present
- Deductible
- $372.09 of $500.0074%
- Out-of-pocket maximum
- $159.97 of $2,000.008%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 9679150778
- Network
- Out of network
- Rendering NPI
- 5570163118
- Location
- Phoenix, AZ · TIN 56-6230971
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 93224 | Holter monitor, 48 hours | — | 1 | 1 | $356.00 | $160.20 | — | — | DeniedCO204 |
| Totals | $356.00 | $160.20 | — | — | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- 2. I50.9 Heart failure, unspecified
- Patient account
- PA-585565
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- 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-036915 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-02: SELECT-EPO (EPO), effective 2021-04-01. | |
| Timely filing | Pass | Received 31 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 | Fail | CO204 | Billing provider 9679150778 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Associates2026-09-02 12:26
Follow-up for atherosclerotic heart disease of native coronary artery without angina. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-10-03 05:59
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 9679150778 is out of network and the EPO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025725 | 2026-07-06 | Canyon Regional Medical Center | $683.00 | Approved |
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
No out-of-network benefit on this plan.