CLM-2026-023653
Sunrise Cardiovascular Associates, Cardiology. Service 2026-04-12 at office (POS 11). Received 2026-05-25.
Member
Resolved through the identity graph
- Member
- Randy Riley
- Member ID
- UHC-06936-55
- Date of birth
- 1975-07-01
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-432715
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group NULL
- Coverage period
- 2025-10-01 to 2026-03-12
- Deductible
- $1,341.04 of $3,500.0038%
- Out-of-pocket maximum
- $1,382.46 of $14,000.0010%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 6315639594
- Network
- Out of network
- Rendering NPI
- 6555229619
- Location
- Austin, TX · TIN 17-4007347
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $332.00 | $149.40 | — | — | DeniedCO27 |
| Totals | $332.00 | $149.40 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-862193
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-032268 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-12 is after coverage terminated on 2026-03-12. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 43 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 | 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 Associates2026-04-12 15:10
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-05-25 05:53
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-05-25 16:11
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-04-12 is after coverage terminated on 2026-03-12. Provider 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-2026-013088 | 2026-05-13 | Mesa Diabetes Center | $758.00 | 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.