CLM-2026-012336
Sunrise Heart Institute, Cardiology. Service 2026-01-06 at outpatient hospital (POS 22). Received 2026-01-11.
Member
Resolved through the identity graph
- Member
- Heather Santiago
- Member ID
- UHC-96448-79
- Date of birth
- 1984-05-12
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-424502
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-5236
- Coverage period
- 2025-05-01 to present
- Deductible
- $100.95 of $500.0020%
- Out-of-pocket maximum
- $335.34 of $1,000.0034%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 7885317132
- Network
- In network
- Rendering NPI
- 6289612205
- Location
- Mesa, AZ · TIN 11-9149520
- 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 | 93015 | Cardiovascular stress test | — | 1 | 1 | $458.00 | $251.90 | $251.90 | $0.00 | Paid |
| Totals | $458.00 | $251.90 | $251.90 | $0.00 | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-686371
- 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-003421 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-06: OPTIONS-PPO (PPO), effective 2025-05-01. | |
| Timely filing | Pass | Received 5 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 Heart Institute (7885317132). | |
| 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 Heart Institute2026-01-06 16:29
Established patient presents with unspecified atrial fibrillation; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-686371.pdf8 pages
Itemised statement totalling $458.00 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
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.