Professional claim · CMS-1500 · EDI 837P
CLM-2026-009276
Sunrise Cardiovascular Associates, Cardiology. Service 2026-05-04 at office (POS 11). Received 2026-05-24.
DeniedOut of network
Billed
$679.00
2 lines
Allowed
$305.55
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 10% coinsurance
Rules engine
Deny
CO27, CO204
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Santiago Miller
- Member ID
- UHC-98037-76
- Date of birth
- 1951-02-23
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-411568
- Relationship
- Spouse, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-5273
- Coverage period
- 2023-01-01 to 2026-01-15
- Deductible
- $344.86 of $2,500.0014%
- Out-of-pocket maximum
- $1,668.06 of $10,000.0017%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 6315639594
- Network
- Out of network
- Rendering NPI
- 6816452562
- Location
- Austin, TX · TIN 17-4007347
- Authorisation / referral
- none / REF636552
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 | — | — | DeniedCO27 |
| 2 | 93224 | Holter monitor, 48 hours | — | 1 | 1,2 | $369.00 | $166.05 | — | — | DeniedCO27 |
| Totals | $679.00 | $305.55 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- 2. I50.9 Heart failure, unspecified
- 3. I10 Essential (primary) hypertension
Claim header
- Patient account
- PA-614428
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-022952 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-04 is after coverage terminated on 2026-01-15. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 20 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 6315639594 is out of network and the HMO 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Cardiovascular Associates2026-05-04 11:51
Patient seen for atherosclerotic heart disease of native coronary artery without angina.
- SystemSystem: Claims system2026-05-24 05:26
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-05-24 12:20
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-05-04 is after coverage terminated on 2026-01-15. Provider network: Billing provider 6315639594 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-003065 | 2026-03-24 | Sunrise Digestive Health Center | $2,709.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Denied by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
DeniedCO27scenario: Coverage terminated
Service after coverage termination.