CLM-2026-009025
Sunrise Cardiovascular Associates, Cardiology. Service 2026-07-05 at office (POS 11). Received 2026-08-17.
Member
Resolved through the identity graph
- Member
- Paul Richardson
- Member ID
- UHC-64897-23
- Date of birth
- 1950-06-09
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-425672
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group GRP-3230
- Coverage period
- 2023-11-01 to present
- Deductible
- $474.69 of $1,000.0047%
- Out-of-pocket maximum
- $832.98 of $4,000.0021%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 6315639594
- Network
- Out of network
- Rendering NPI
- 1884150222
- Location
- Austin, TX · TIN 17-4007347
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $310.00 | $139.50 | $40.00 | $99.50 | Paid |
| Totals | $310.00 | $139.50 | $40.00 | $99.50 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. I25.10 Atherosclerotic heart disease of native coronary artery without angina
- 3. I10 Essential (primary) hypertension
- Patient account
- PA-217445
- 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-032227 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-07-05: UNKNOWN (PPO), effective 2023-11-01. | |
| Timely filing | Pass | Received 43 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 Associates2026-07-05 18:27
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-08-17 02:30
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-08-17 08:31
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-217445.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
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
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
Authorisation must be confirmed with UM before payment.