CLM-2026-015870
Sunrise Cardiovascular Associates, Cardiology. Service 2026-03-20 at outpatient hospital (POS 22). Received 2026-04-20.
Member
Resolved through the identity graph
- Member
- Arthur Contreras
- Member ID
- UHC-78188-71
- Date of birth
- 1943-10-20
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-405013
- Relationship
- Spouse, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-7211
- Coverage period
- 2025-01-01 to present
- Deductible
- $790.92 of $1,000.0079%
- Out-of-pocket maximum
- $610.00 of $4,000.0015%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 6315639594
- Network
- Out of network
- Rendering NPI
- 3416802809
- Location
- Austin, TX · TIN 17-4007347
- Authorisation / referral
- PA2026818388 / 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 | $437.00 | $196.65 | — | — | DeniedCO204 |
| 2 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $7,201.00 | $3,240.45 | — | — | DeniedCO204 |
| Totals | $7,638.00 | $3,437.10 | — | — | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- Patient account
- PA-991195
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-016594 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-20: SELECT-EPO (EPO), effective 2025-01-01. | |
| Timely filing | Pass | Received 31 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026818388 on file for 93458. | |
| Provider network | Fail | CO204 | Billing provider 6315639594 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Associates2026-03-20 17:04
Follow-up for heart failure, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-04-20 06:41
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-04-20 10:16
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterPA2026818388_approval.pdf2 pages
Utilisation management approval letter for 93015 (Cardiovascular stress test), valid 2026-03-20 to 2026-06-18.
- Itemized billitemized_PA-991195.pdf3 pages
Itemised statement totalling $7638.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 6315639594 is out of network and the EPO plan has no out-of-network benefit.
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
No out-of-network benefit on this plan.