CLM-2026-013266
Sunrise Heart Institute, Cardiology. Service 2026-08-09 at outpatient hospital (POS 22). Received 2026-09-23.
Member
Resolved through the identity graph
- Member
- Nancy Munoz
- Member ID
- UHC-50527-20
- Date of birth
- 1947-05-03
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-402051
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-4913
- Coverage period
- 2021-12-01 to present
- Deductible
- $1,381.76 of $2,500.0055%
- Out-of-pocket maximum
- $1,729.49 of $5,000.0035%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 7885317132
- Network
- In network
- Rendering NPI
- 6231327423
- 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 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,114.00 | $612.70 | $612.70 | $0.00 | Paid |
| 2 | 93015 | Cardiovascular stress test | — | 1 | 2 | $655.00 | $360.25 | $360.25 | $0.00 | Paid |
| Totals | $1,769.00 | $972.95 | $972.95 | $0.00 | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-757465
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-010544 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-09: MEDICARE-ADV-B (MA), effective 2021-12-01. | |
| Timely filing | Pass | Received 45 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 Institute2026-08-09 14:07
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-757465.pdf7 pages
Itemised statement totalling $1769.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017785 | 2026-08-23 | Pinecrest Medical Group | $56.00 | Needs review |
| CLM-2026-017784 | 2026-08-23 | Pinecrest Medical Group | $56.00 | Approved |
| CLM-2026-026108 | 2026-02-21 | Meadow Family Practice | $327.00 | 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.