Claims workbench/CLM-2026-025462

Institutional claim · UB-04 · Provider portal

CLM-2026-025462

Sunrise Cardiovascular Associates, Cardiology. Service 2025-12-26 at outpatient hospital (POS 22). Received 2026-02-03.

DeniedOut of network

Billed

$1,909.00

2 lines

Allowed

$859.05

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO204

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Melissa Maldonado
Member ID: UHC-80701-58
Date of birth: 1971-06-16
Identity: Verified6 records, confidence 1.00
Claim record: CLMCLM-430128
Relationship: Self, San Antonio, TX

Coverage and accumulators

Found by member ID

Plan: NAVIGATE-HMO HMO group GRP-5911
Coverage period: 2021-06-01 to present
Deductible: $374.38 of $500.0075%
Out-of-pocket maximum: $203.09 of $2,000.0010%
Copays: office $30.00, specialist $75.00, emergency $150.00
Physical therapy visits: 19 of 20 used

Provider

Billing and rendering

Billing provider: Sunrise Cardiovascular Associates
Cardiology · taxonomy 207RC0000X
NPI: 6315639594
Network: Out of network
Rendering NPI: 3129521225
Location: Austin, TX · TIN 17-4007347
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	93306 rev 0480	Echocardiogram, complete	—	1	1	$1,417.00	$637.65	—	—	DeniedCO204
2	93015	Cardiovascular stress test	25	1	1,2	$492.00	$221.40	—	—	DeniedCO204
Totals						$1,909.00	$859.05	—	—

Diagnoses (ICD-10-CM)

1. I50.9 Heart failure, unspecifiedprincipal
2. I10 Essential (primary) hypertension
3. R07.9 Chest pain, unspecified

Claim header

Patient account: PA-325729
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-010141 (verified, link confidence 1.00).
Eligibility	Pass		Active on 2025-12-26: NAVIGATE-HMO (HMO), effective 2021-06-01.
Timely filing	Pass		Received 39 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 6315639594 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.

Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Sunrise Cardiovascular Associates2025-12-26 11:05
Established patient presents with heart failure, unspecified; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-02-03 01:18
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)2026-02-03 09:01
Member services inquiry logged on this claim; member asked about the status of payment.

Attachments

Documents received with the claim

Itemized billitemized_PA-325729.pdf2 pages
Itemised statement totalling $1909.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Provider network: Billing provider 6315639594 is out of network and the HMO plan has no out-of-network benefit.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-011463	2026-07-20	Pinecrest Bone and Joint Center	$9,982.00	Denied
CLM-2026-011346	2026-03-16	Canyon Reference Lab	$49.00	Approved
CLM-2026-005108	2026-02-12	Meadow Heart Institute	$580.00	Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

DeniedCO204scenario: Oon hmo

No out-of-network benefit on this plan.

Review queue Member identity