CLM-2026-015127
Sunrise Cardiovascular Associates, Cardiology. Service 2026-02-27 at office (POS 11). Received 2026-03-28.
Member
Resolved through the identity graph
- Member
- Jacob Schmidt
- Member ID
- UHC-25356-26
- Date of birth
- 1969-03-25
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-417796
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-8489
- Coverage period
- 2022-04-01 to present
- Deductible
- $1,512.51 of $2,500.0061%
- Out-of-pocket maximum
- $1,213.88 of $5,000.0024%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4904880653
- Network
- In network
- Rendering NPI
- 3969385954
- Location
- Charlotte, NC · TIN 94-7029927
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99214 | Office visit, established patient, moderate complexity | 59 | 1 | 1 | $222.00 | $137.64 | — | — | Review |
| 2 | 93224 | Holter monitor, 48 hours | 59 | 1 | 1 | $364.00 | $225.68 | — | — | Review |
| Totals | $586.00 | $363.32 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-277870
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-009351 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-02-27: MEDICARE-ADV-B (MA), effective 2022-04-01. | |
| Timely filing | Pass | Received 29 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) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Associates2026-02-27 17:17
Patient seen for unspecified atrial fibrillation. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-03-28 02:03
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-03-28 09:02
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Medical recordrecords_PA-277870.pdf6 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020237 | 2026-02-28 | Meadow Imaging Center | $3,585.00 | Needs review |
| CLM-2026-022175 | 2026-01-27 | Heritage Rehabilitation Center | $367.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Bundled code pair; modifier 59 not supported by the operative note.