CLM-2026-016770
Sunrise Cardiovascular Associates, Cardiology. Service 2026-04-04 at outpatient hospital (POS 22). Received 2026-04-14.
Member
Resolved through the identity graph
- Member
- Gary Rice
- Member ID
- UHC-62341-88
- Date of birth
- 1961-06-26
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-404100
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-9570
- Coverage period
- 2021-09-01 to present
- Deductible
- $332.80 of $500.0067%
- Out-of-pocket maximum
- $63.69 of $1,500.004%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 9679150778
- Network
- Out of network
- Rendering NPI
- 2081036941
- 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 | $1,402.00 | $630.90 | — | — | PendedIDQ |
| 2 | 93015 | Cardiovascular stress test | — | 1 | 1 | $651.00 | $292.95 | — | — | PendedIDQ |
| Totals | $2,053.00 | $923.85 | — | — | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- Patient account
- PA-824814
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-001150; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-04-04: - (PPO), effective 2021-09-01. | |
| Timely filing | Pass | Received 10 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 | 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 Associates2026-04-04 11:22
Patient seen for heart failure, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-824814.pdf6 pages
Itemised statement totalling $2053.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-001150; payment withheld until the identity is confirmed. 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
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.