CLM-2026-016902
Sunrise Cardiovascular Associates, Cardiology. Service 2026-09-05 at office (POS 11). Received 2026-10-03.
Member
Resolved through the identity graph
- Member
- Albert Daniels
- Member ID
- UHC-88907-28
- Date of birth
- 1954-05-11
- Identity
- Verified4 records, confidence 0.98
- Claim record
- CLMCLM-416338
- Relationship
- Spouse, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8413
- Coverage period
- 2024-11-01 to present
- Deductible
- $374.42 of $500.0075%
- Out-of-pocket maximum
- $380.06 of $1,000.0038%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 6315639594
- Network
- Out of network
- Rendering NPI
- 1933685277
- Location
- Austin, TX · TIN 17-4007347
- Authorisation / referral
- none / REF639929
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 | 93224 | Holter monitor, 48 hours | — | 1 | 1 | $356.00 | $160.20 | — | — | DeniedCO204 |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $281.00 | $126.45 | — | — | DeniedCO204 |
| Totals | $637.00 | $286.65 | — | — | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- 2. I25.10 Atherosclerotic heart disease of native coronary artery without angina
- 3. I10 Essential (primary) hypertension
- Patient account
- PA-289772
- 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-016082 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2026-09-05: CORE-HMO (HMO), effective 2024-11-01. | |
| Timely filing | Pass | Received 28 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 | Fail | CO204 | Billing provider 6315639594 is out of network and the HMO 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 Associates2026-09-05 13:08
Established patient presents with heart failure, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-10-03 01:54
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-10-03 08:00
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
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 HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-008427 | 2026-06-14 | Desert Internal Medicine Associates | $296.00 | Approved |
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.