CLM-2026-021050
Sunrise Cardiovascular Associates, Cardiology. Service 2026-08-05 at outpatient hospital (POS 22). Received 2026-09-09.
Member
Resolved through the identity graph
- Member
- Nicole Bryant
- Member ID
- UHC-87960-16
- Date of birth
- 1973-03-24
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-424380
- Relationship
- Spouse, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-1045
- Coverage period
- 2023-10-01 to present
- Deductible
- $1,262.59 of $1,500.0084%
- Out-of-pocket maximum
- $1,620.94 of $6,000.0027%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 9679150778
- Network
- Out of network
- Rendering NPI
- 5997875120
- Location
- Phoenix, AZ · TIN 56-6230971
- Authorisation / referral
- PA2025543942 / 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 | $7,785.00 | $3,503.25 | $890.58 | $2,612.67 | Paid |
| 2 | 93306 rev 0480 | Echocardiogram, complete | 25 | 1 | 2 | $1,287.00 | $579.15 | $115.83 | $463.32 | Paid |
| Totals | $9,072.00 | $4,082.40 | $1,006.41 | $3,075.99 | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. I25.10 Atherosclerotic heart disease of native coronary artery without angina
- 3. R07.9 Chest pain, unspecified
- Patient account
- PA-123611
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-025513 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-05: MEDICARE-ADV-A (MA), effective 2023-10-01. | |
| Timely filing | Pass | Received 35 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025543942 on file for 93458. | |
| 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 Associates2026-08-05 16:01
Patient seen for unspecified atrial fibrillation.
Attachments
Documents received with the claim
- Prior auth letterPA2025543942_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-08-05 to 2026-11-03.
- Itemized billitemized_PA-123611.pdf6 pages
Itemised statement totalling $9072.00 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 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031224 | 2026-08-14 | Summit Regional Medical Center | $141.00 | Approved |
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.