CLM-2026-011667
Sunrise Cardiovascular Associates, Cardiology. Service 2026-02-07 at outpatient hospital (POS 22). Received 2026-03-17.
Member
Resolved through the identity graph
- Member
- Sean Perkins
- Member ID
- UHC-05438-97
- Date of birth
- 1943-10-17
- Identity
- Verified3 records, confidence 0.93
- Claim record
- CLMCLM-425413
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-1009
- Coverage period
- 2023-01-01 to present
- Deductible
- $412.53 of $500.0083%
- Out-of-pocket maximum
- $157.69 of $1,000.0016%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 7132857724
- Network
- In network
- Rendering NPI
- 2085832899
- 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 | $1,455.00 | $800.25 | $158.75 | $641.50 | Paid |
| Totals | $1,455.00 | $800.25 | $158.75 | $641.50 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-429174
- 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-020347 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-02-07: N/A (PPO), effective 2023-01-01. | |
| Timely filing | Pass | Received 38 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 Associates2026-02-07 14:10
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-429174.pdf6 pages
Itemised statement totalling $1455.00 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-2026-022145 | 2026-04-23 | Canyon Heart Institute | $1,053.00 | 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.