CLM-2026-029231
Sunrise Cardiovascular Associates, Cardiology. Service 2026-01-05 at outpatient hospital (POS 22). Received 2026-01-29.
Member
Resolved through the identity graph
- Member
- Willie Chen
- Member ID
- none on golden record
- Date of birth
- 1948-01-05
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-401472
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- MEDICARE-ADV-A MA group GRP-3412
- Coverage period
- 2023-11-01 to present
- Deductible
- $2,433.87 of $3,500.0070%
- Out-of-pocket maximum
- $518.08 of $10,500.005%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4904880653
- Network
- In network
- Rendering NPI
- 9221805903
- Location
- Charlotte, NC · TIN 94-7029927
- Authorisation / referral
- PA2025502744 / 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 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $8,382.00 | $4,610.10 | — | — | PendedIDQ |
| Totals | $8,382.00 | $4,610.10 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. I25.10 Atherosclerotic heart disease of native coronary artery without angina
- Patient account
- PA-388994
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-002144; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-01-05: MEDICARE-ADV-A (MA), effective 2023-11-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025502744 on file for 93458. | |
| Provider network | Pass | In-network provider Sunrise Cardiovascular Associates (4904880653). | |
| 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 Associates2026-01-05 09:01
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025502744_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-01-05 to 2026-04-05.
- Itemized billitemized_PA-388994.pdf7 pages
Itemised statement totalling $8382.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-002144; payment withheld until the identity is confirmed. Eligibility: Active on 2026-01-05: MEDICARE-ADV-A (MA), effective 2023-11-01. Coverage found by name and date of birth because the claim carried no usable member ID.
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
Clean claim, priced at contract rate.