CLM-2026-020772
Sunrise Heart Institute, Cardiology. Service 2026-09-04 at outpatient hospital (POS 22). Received 2026-10-11.
Member
Resolved through the identity graph
- Member
- Alexander Pena
- Member ID
- UHC-14599-26
- Date of birth
- 1965-11-10
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-409187
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-0328
- Coverage period
- 2024-01-01 to present
- Deductible
- $522.69 of $1,000.0052%
- Out-of-pocket maximum
- $734.16 of $4,000.0018%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 7885317132
- Network
- In network
- Rendering NPI
- 1766543858
- Location
- Mesa, AZ · TIN 11-9149520
- Authorisation / referral
- PA2026254416 / 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 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $9,096.00 | $5,002.80 | $1,382.41 | $3,620.39 | Paid |
| 2 | 93015 | Cardiovascular stress test | — | 1 | 1,2 | $440.00 | $242.00 | $48.40 | $193.60 | Paid |
| Totals | $9,536.00 | $5,244.80 | $1,430.81 | $3,813.99 | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-778440
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-030785 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-04: OPTIONS-PPO (PPO), effective 2024-01-01. | |
| Timely filing | Pass | Received 37 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026254416 on file for 93458. | |
| Provider network | Pass | In-network provider Sunrise Heart Institute (7885317132). | |
| 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 Heart Institute2026-09-04 14:04
Patient seen for heart failure, unspecified.
Attachments
Documents received with the claim
- Prior auth letterPA2026254416_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-09-04 to 2026-12-03.
- Itemized billitemized_PA-778440.pdf2 pages
Itemised statement totalling $9536.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
- AI recommendation recordedcli_adjudicator2026-10-21 13:39 · c066f095
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.