CLM-2026-019819
Sunrise Cardiovascular Associates, Cardiology. Service 2026-06-29 at outpatient hospital (POS 22). Received 2026-08-07.
Member
Resolved through the identity graph
- Member
- Bobby Cooper
- Member ID
- UHC-84475-10
- Date of birth
- 1998-12-01
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-403950
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-2736
- Coverage period
- 2022-08-01 to present
- Deductible
- $73.43 of $2,500.003%
- Out-of-pocket maximum
- $3,686.45 of $7,500.0049%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 6315639594
- Network
- Out of network
- Rendering NPI
- 7582732385
- Location
- Austin, TX · TIN 17-4007347
- Authorisation / referral
- none / REF958999
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 | $1,141.00 | $513.45 | — | — | DeniedCO204 |
| 2 | 93015 | Cardiovascular stress test | — | 1 | 2 | $363.00 | $163.35 | — | — | DeniedCO204 |
| Totals | $1,504.00 | $676.80 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. I25.10 Atherosclerotic heart disease of native coronary artery without angina
- Patient account
- PA-209213
- 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-007009 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-29: CORE-HMO (HMO), effective 2022-08-01. | |
| Timely filing | Pass | Received 39 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 Associates2026-06-29 17:38
Patient seen for chest pain, unspecified.
- SystemSystem: Claims system2026-08-07 03:58
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
- Itemized billitemized_PA-209213.pdf6 pages
Itemised statement totalling $1504.00 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 HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021233 | 2026-08-06 | Pinecrest Physical Therapy | $519.00 | Denied |
| CLM-2026-028020 | 2026-05-29 | Evergreen Orthopedic Specialists | $163.00 | 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.