CLM-2026-026315
Sunrise Heart Institute, Cardiology. Service 2026-07-25 at outpatient hospital (POS 22). Received 2026-09-04.
Member
Resolved through the identity graph
- Member
- Nancy Rojas
- Member ID
- UHC-59612-31
- Date of birth
- 2007-10-03
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-428409
- Relationship
- Child, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-1669
- Coverage period
- 2024-05-01 to present
- Deductible
- $118.42 of $3,500.003%
- Out-of-pocket maximum
- $2,791.31 of $10,500.0027%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 7885317132
- Network
- In network
- Rendering NPI
- 9363288298
- Location
- Mesa, AZ · TIN 11-9149520
- Authorisation / referral
- none / REF246043
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 | $1,267.00 | $696.85 | $696.85 | $0.00 | Paid |
| Totals | $1,267.00 | $696.85 | $696.85 | $0.00 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. I50.9 Heart failure, unspecified
- Patient account
- PA-490126
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-017901 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-25: CORE-HMO (HMO), effective 2024-05-01. | |
| Timely filing | Pass | Received 41 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 Heart Institute (7885317132). | |
| 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 Heart Institute2026-07-25 11:31
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-490126.pdf5 pages
Itemised statement totalling $1267.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.