CLM-2026-023924
Sunrise Cardiovascular Associates, Cardiology. Service 2026-08-20 at outpatient hospital (POS 22). Received 2026-09-06.
Member
Resolved through the identity graph
- Member
- Judy Morrison
- Member ID
- UHC-54028-49
- Date of birth
- 1964-06-15
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-432269
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-0902
- Coverage period
- 2022-01-01 to 2026-08-15
- Deductible
- $1,202.06 of $1,500.0080%
- Out-of-pocket maximum
- $2,631.04 of $6,000.0044%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4904880653
- Network
- In network
- Rendering NPI
- 2936884925
- Location
- Charlotte, NC · TIN 94-7029927
- Authorisation / referral
- none / REF556658
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 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,376.00 | $756.80 | — | — | DeniedCO27 |
| Totals | $1,376.00 | $756.80 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-349476
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- 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-015986 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-20 is after coverage terminated on 2026-08-15. 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 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 Associates2026-08-20 09:37
Patient seen for chest pain, unspecified.
- SystemSystem: Claims system2026-09-06 03:04
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-09-06 10:05
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-349476.pdf9 pages
Itemised statement totalling $1376.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-08-20 is after coverage terminated on 2026-08-15.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012735 | 2026-07-08 | Valley Reference Lab | $113.00 | Approved |
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.