CLM-2026-008835
Sunrise Cardiovascular Associates, Cardiology. Service 2026-06-16 at outpatient hospital (POS 22). Received 2026-07-16.
Member
Resolved through the identity graph
- Member
- Teresa Vargas
- Member ID
- UHC-52653-73
- Date of birth
- 1944-05-14
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-428080
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-4426
- Coverage period
- 2023-06-01 to present
- Deductible
- $1,111.84 of $2,500.0044%
- Out-of-pocket maximum
- $3,390.18 of $7,500.0045%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 7132857724
- Network
- In network
- Rendering NPI
- 2045177245
- Location
- Charlotte, NC · TIN 50-7613597
- 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 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $911.00 | $501.05 | — | — | PendedIDQ |
| 2 | 93015 | Cardiovascular stress test | 25 | 1 | 1 | $536.00 | $294.80 | — | — | PendedIDQ |
| Totals | $1,447.00 | $795.85 | — | — | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-413368
- 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 | Fail | IDQ | Member record is in open steward case CASE-004224; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-06-16: MEDICARE-ADV-A (MA), effective 2023-06-01. | |
| Timely filing | Pass | Received 30 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 Cardiovascular Associates (7132857724). | |
| 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 Associates2026-06-16 13:27
Follow-up for atherosclerotic heart disease of native coronary artery without angina. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-413368.pdf5 pages
Itemised statement totalling $1447.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-004224; payment withheld until the identity is confirmed.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.