CLM-2026-015073
Sunrise Cardiovascular Associates, Cardiology. Service 2025-10-04 at outpatient hospital (POS 22). Received 2026-01-21.
Member
Resolved through the identity graph
- Member
- Sean Gordon
- Member ID
- none on golden record
- Date of birth
- 1948-09-19
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-427068
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- OPTIONS-PPO PPO group GRP-9909
- Coverage period
- 2022-12-01 to present
- Deductible
- $939.66 of $1,500.0063%
- Out-of-pocket maximum
- $839.28 of $4,500.0019%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 9679150778
- Network
- Out of network
- Rendering NPI
- 4371935337
- Location
- Phoenix, AZ · TIN 56-6230971
- 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 | $1,298.00 | $584.10 | — | — | DeniedCO29 |
| Totals | $1,298.00 | $584.10 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-916035
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 4 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-000009; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2025-10-04: OPTIONS-PPO (PPO), effective 2022-12-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Fail | CO29 | Received 109 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Associates2025-10-04 12:14
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-01-21 02:39
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-01-21 17:04
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-916035.pdf8 pages
Itemised statement totalling $1298.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Member identity: Member record is in open steward case CASE-000009; payment withheld until the identity is confirmed. Eligibility: Active on 2025-10-04: OPTIONS-PPO (PPO), effective 2022-12-01. Coverage found by name and date of birth because the claim carried no usable member ID. Timely filing: Received 109 days after the last date of service (limit 90). Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Received after the timely-filing limit.