CLM-2026-021867
Sunrise Cardiovascular Associates, Cardiology. Service 2026-08-07 at outpatient hospital (POS 22). Received 2026-08-31.
Member
Resolved through the identity graph
- Member
- Rebecca Austin
- Member ID
- UHC-39143-11
- Date of birth
- 1983-03-26
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-405396
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-2063
- Coverage period
- 2021-12-01 to present
- Deductible
- $775.01 of $1,500.0052%
- Out-of-pocket maximum
- $2,456.04 of $6,000.0041%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4904880653
- Network
- In network
- Rendering NPI
- 7026777640
- Location
- Charlotte, NC · TIN 94-7029927
- Authorisation / referral
- PA2025698549 / 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 | $6,237.00 | $3,430.35 | $995.53 | $2,434.82 | Paid |
| Totals | $6,237.00 | $3,430.35 | $995.53 | $2,434.82 | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- 2. I50.9 Heart failure, unspecified
- Patient account
- PA-681369
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-034784 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-07: SELECT-EPO (EPO), effective 2021-12-01. | |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025698549 on file for 93458. | |
| Provider network | Pass | In-network provider Sunrise Cardiovascular Associates (4904880653). | |
| 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 Associates2026-08-07 13:40
Follow-up for atherosclerotic heart disease of native coronary artery without angina. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025698549_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-08-07 to 2026-11-05.
- Itemized billitemized_PA-681369.pdf4 pages
Itemised statement totalling $6237.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030448 | 2026-08-14 | Mesa Clinical Laboratories | $138.00 | Approved |
| CLM-2026-018813 | 2026-09-12 | Sunrise Community Hospital | $178.00 | 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.