CLM-2026-023989
Sunrise Cardiovascular Associates, Cardiology. Service 2026-08-20 at outpatient hospital (POS 22). Received 2026-10-02.
Member
Resolved through the identity graph
- Member
- Kelly Flores
- Member ID
- UHC-81413-97
- Date of birth
- 1962-07-20
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-408580
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5140
- Coverage period
- 2023-05-01 to present
- Deductible
- $770.07 of $3,500.0022%
- Out-of-pocket maximum
- $5,142.60 of $10,500.0049%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 9679150778
- Network
- Out of network
- Rendering NPI
- 7914336202
- Location
- Phoenix, AZ · TIN 56-6230971
- Authorisation / referral
- none / REF684245
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 | $1,133.00 | $509.85 | — | — | DeniedCO204 |
| Totals | $1,133.00 | $509.85 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. I50.9 Heart failure, unspecified
- Patient account
- PA-500318
- 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-044084 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-08-20: NAVIGATE-HMO (HMO), effective 2023-05-01. | |
| 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 | Fail | CO204 | Billing provider 9679150778 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 15:14
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-10-02 03:38
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-10-02 16:22
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-500318.pdf5 pages
Itemised statement totalling $1133.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 9679150778 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
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
No out-of-network benefit on this plan.