Claims workbench/CLM-2026-019291

Institutional claim · UB-04 · EDI 837I

CLM-2026-019291

Sunrise Cardiovascular Associates, Cardiology. Service 2026-08-19 at outpatient hospital (POS 22). Received 2026-09-23.

Needs review

Billed

$1,739.00

2 lines

Allowed

$956.45

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Review

CO16

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Nicole Carlson
Member ID: UHC-64211-07
Date of birth: 1941-10-20
Identity: Verified5 records, confidence 0.99
Claim record: CLMCLM-419633
Relationship: Self, Tampa, FL

Coverage and accumulators

Found by member ID

Plan: CORE-HMO HMO group GRP-0483
Coverage period: 2024-12-01 to present
Deductible: $109.51 of $3,500.003%
Out-of-pocket maximum: $4,111.29 of $10,500.0039%
Copays: office $20.00, specialist $40.00, emergency $150.00
Physical therapy visits: 18 of 20 used

Provider

Billing and rendering

Billing provider: Sunrise Cardiovascular Associates
Cardiology · taxonomy 207RC0000X
NPI: 4663411393
Network: In network
Rendering NPI: 8568450315
Location: Tampa, FL · TIN 46-7082027
Authorisation / referral: none / REF881364

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	$520.00	$286.00	—	—	Review
2	93306 rev 0480	Echocardiogram, complete	—	1	1	$1,219.00	$670.45	—	—	Review
Totals						$1,739.00	$956.45	—	—

Diagnoses (ICD-10-CM)

1. I48.91 Unspecified atrial fibrillationprincipal
2. I25.10 Atherosclerotic heart disease of native coronary artery without angina

Claim header

Patient account: PA-996230
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-007585 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-08-19: CORE-HMO (HMO), effective 2024-12-01.
Timely filing	Pass		Received 35 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 (4663411393).
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Pass		No bundling conflicts.
Benefit limits	Pass		No limited benefit on this claim.
Completeness	Review	CO16	Documentation incomplete: “Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled. Not”. Claim lacks information needed for adjudication
High-dollar review	Pass		Within the auto-adjudication ceiling.

Evaluated 2026-10-21 13:43 under policy version 1. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Sunrise Cardiovascular Associates2026-08-19 18:58
Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled. Note dictated; signature pending.
SystemSystem: Claims system2026-09-23 03:04
Rendering provider signature missing on the attached note. Development letter sent to provider.
AdministrativeExaminer: R. Patel (Claims Examiner II)2026-09-23 14:16
Member services inquiry logged on this claim; member asked about the status of payment.

Attachments

Documents received with the claim

Itemized billitemized_PA-996230.pdf8 pages
Itemised statement totalling $1739.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Completeness: Documentation incomplete: “Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled. Not”.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-011172	2026-03-16	Unity Community Hospital	$3,330.00	Approved
CLM-2026-004110	2026-01-19	Desert Regional Medical Center	$987.00	Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

The rules engine left this claim for review. The AI adjudicator can read the evidence pack (lines, notes, attachments, coverage, history) and recommend an outcome with citations.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

PendedCO16scenario: Missing info

Development letter outstanding.

Review queue Member identity