CLM-2026-022359
Sunrise Heart Institute, Cardiology. Service 2026-06-19 at outpatient hospital (POS 22). Received 2026-07-06.
Member
Resolved through the identity graph
- Member
- Janice Herrera
- Member ID
- UHC-91917-46
- Date of birth
- 1986-09-18
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-415024
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3803
- Coverage period
- 2023-02-01 to 2026-06-10
- Deductible
- $231.31 of $500.0046%
- Out-of-pocket maximum
- $250.45 of $1,000.0025%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 7885317132
- Network
- In network
- Rendering NPI
- 8865547326
- Location
- Mesa, AZ · TIN 11-9149520
- Authorisation / referral
- none / 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 | 93015 | Cardiovascular stress test | — | 1 | 1 | $449.00 | $246.95 | — | — | DeniedCO27 |
| Totals | $449.00 | $246.95 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. I25.10 Atherosclerotic heart disease of native coronary artery without angina
- Patient account
- PA-313038
- 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-037536 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-19 is after coverage terminated on 2026-06-10. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 17 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 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 Institute2026-06-19 15:14
Established patient presents with unspecified atrial fibrillation; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-06 04:10
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-07-06 14:59
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-313038.pdf6 pages
Itemised statement totalling $449.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-06-19 is after coverage terminated on 2026-06-10.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002353 | 2026-09-07 | Meadow Family Practice | $209.00 | Denied |
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
Service after coverage termination.