CLM-2026-008685
Sunrise Cardiovascular Associates, Cardiology. Service 2026-02-25 at outpatient hospital (POS 22). Received 2026-09-10.
Member
Resolved through the identity graph
- Member
- Randy Sims
- Member ID
- UHC-91736-60
- Date of birth
- 1983-10-01
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-412023
- Relationship
- Spouse, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-9216
- Coverage period
- 2025-04-01 to present
- Deductible
- $622.91 of $1,000.0062%
- Out-of-pocket maximum
- $240.96 of $2,000.0012%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4663411393
- Network
- In network
- Rendering NPI
- 1477765212
- Location
- Tampa, FL · TIN 46-7082027
- Authorisation / referral
- PA2026830729 / 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 | $5,465.00 | $3,005.75 | — | — | DeniedCO29 |
| Totals | $5,465.00 | $3,005.75 | — | — | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-957870
- 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-012073 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-25: MEDICARE-ADV-B (MA), effective 2025-04-01. | |
| Timely filing | Fail | CO29 | Received 197 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026830729 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 Associates2026-02-25 14:43
Established patient presents with atherosclerotic heart disease of native coronary artery without angina; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-10 03:24
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-09-10 08:27
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Prior auth letterPA2026830729_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-02-25 to 2026-05-26.
- Itemized billitemized_PA-957870.pdf6 pages
Itemised statement totalling $5465.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 197 days after the last date of service (limit 90).
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
Received after the timely-filing limit.