CLM-2026-024618
Sunrise Cardiovascular Associates, Cardiology. Service 2026-07-21 at outpatient hospital (POS 22). Received 2026-08-20.
Member
Resolved through the identity graph
- Member
- Kevin Rice
- Member ID
- none on golden record
- Date of birth
- 2000-08-06
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-408906
- Relationship
- Spouse, Chandler, AZ
Coverage and accumulators
Eligibility
Provider
Billing and rendering
- Billing provider
- Sunrise Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 9679150778
- Network
- Out of network
- Rendering NPI
- 8509090881
- Location
- Phoenix, AZ · TIN 56-6230971
- Authorisation / referral
- PA2026613691 / REF201746
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 | $8,839.00 | $3,977.55 | — | — | PendedIDQ |
| Totals | $8,839.00 | $3,977.55 | — | — | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- Patient account
- PA-379018
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-000519; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 30 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026613691 on file for 93458. | |
| 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 Associates2026-07-21 17:05
Follow-up for atherosclerotic heart disease of native coronary artery without angina. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-20 02:07
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-08-20 09:38
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterPA2026613691_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-07-21 to 2026-10-19.
- Itemized billitemized_PA-379018.pdf5 pages
Itemised statement totalling $8839.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-000519; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim. 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
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
No out-of-network benefit on this plan.