Professional claim · CMS-1500 · EDI 837P
CLM-2026-009756
Sunrise Cardiovascular Associates, Cardiology. Service 2026-08-22 at office (POS 11). Received 2026-09-20.
Approved
Billed
$678.00
2 lines
Allowed
$420.36
contract rate applied
Plan pays
$370.36
approved
Member owes
$50.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Robert Wagner
- Member ID
- UHC-47936-01
- Date of birth
- 1983-01-15
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-431633
- Relationship
- Child, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9585
- Coverage period
- 2024-07-01 to present
- Deductible
- $1,228.05 of $2,500.0049%
- Out-of-pocket maximum
- $2,315.72 of $10,000.0023%
- Copays
- office $40.00, specialist $50.00, 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
- 9415320875
- Location
- Charlotte, NC · TIN 50-7613597
- Authorisation / referral
- none / REF111239
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 | $315.00 | $195.30 | $50.00 | $145.30 | Paid |
| 2 | 93224 | Holter monitor, 48 hours | 25 | 1 | 1 | $363.00 | $225.06 | $0.00 | $225.06 | Paid |
| Totals | $678.00 | $420.36 | $50.00 | $370.36 | ||||||
Diagnoses (ICD-10-CM)
- 1. I50.9 Heart failure, unspecifiedprincipal
Claim header
- Patient account
- PA-251356
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-040773 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-22: CORE-HMO (HMO), effective 2024-07-01. | |
| Timely filing | Pass | Received 29 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. |
Evaluated 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Cardiovascular Associates2026-08-22 10:04
Patient seen for heart failure, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$678.00
Plan discount
$257.64
contracted rate
Plan paid
$370.36
You may owe
$50.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
No other claims.
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved 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
Approvedscenario: Clean
Clean claim, priced at contract rate.