CLM-2026-026759
Sunrise Heart Institute, Cardiology. Service 2026-05-21 at office (POS 11). Received 2026-06-11.
Member
Resolved through the identity graph
- Member
- Diana Butler
- Member ID
- UHC-83959-10
- Date of birth
- 1944-05-24
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-402130
- Relationship
- Spouse, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-5742
- Coverage period
- 2025-11-01 to present
- Deductible
- $303.33 of $1,000.0030%
- Out-of-pocket maximum
- $506.53 of $3,000.0017%
- Copays
- office $30.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 7885317132
- Network
- In network
- Rendering NPI
- 6262164638
- Location
- Mesa, AZ · TIN 11-9149520
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $250.00 | $155.00 | — | — | DeniedCO18 |
| Totals | $250.00 | $155.00 | — | — | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- 2. R07.9 Chest pain, unspecified
- 3. I25.10 Atherosclerotic heart disease of native coronary artery without angina
- Patient account
- PA-277728
- 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-023774 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-05-21: SELECT-EPO (EPO), effective 2025-11-01. | |
| Timely filing | Pass | Received 21 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-026758: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| 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 Institute2026-05-21 14:11
Established patient presents with heart failure, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-11 04:33
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-026758: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-008817 | 2026-04-27 | Sunrise GI Associates | $245.00 | Approved |
| CLM-2026-026758 | 2026-05-21 | Sunrise Heart Institute | $250.00 | 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
Exact duplicate of an earlier submission.