CLM-2026-010528
Sunrise Cardiovascular Associates, Cardiology. Service 2026-07-12 at outpatient hospital (POS 22). Received 2026-08-05.
Member
Resolved through the identity graph
- Member
- Cynthia Burton
- Member ID
- UHC-26454-12
- Date of birth
- 1960-07-26
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-403988
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9390
- Coverage period
- 2025-09-01 to present
- Deductible
- $286.75 of $2,500.0011%
- Out-of-pocket maximum
- $662.23 of $5,000.0013%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4904880653
- Network
- In network
- Rendering NPI
- 3757392931
- Location
- Charlotte, NC · TIN 94-7029927
- Authorisation / referral
- none / REF934263
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 | 93015 | Cardiovascular stress test | — | 1 | 1 | $679.00 | $373.45 | $373.45 | $0.00 | Paid |
| Totals | $679.00 | $373.45 | $373.45 | $0.00 | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-821644
- 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-027683 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-12: CORE-HMO (HMO), effective 2025-09-01. | |
| Timely filing | Pass | Received 24 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 (4904880653). | |
| 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 Associates2026-07-12 12:45
Patient seen for unspecified atrial fibrillation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-821644.pdf5 pages
Itemised statement totalling $679.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010423 | 2026-07-19 | Lakeside Medical Group | $545.00 | Approved |
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
Clean claim, priced at contract rate.