Professional claim · CMS-1500 · EDI 837P
CLM-2026-029242
Sunrise Cardiovascular Associates, Cardiology. Service 2026-06-16 at office (POS 11). Received 2026-07-02.
ApprovedOut of network
Billed
$335.00
1 line
Allowed
$150.75
contract rate applied
Plan pays
$75.75
approved
Member owes
$75.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Jonathan Woods
- Member ID
- UHC-89716-42
- Date of birth
- 1970-07-25
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-421532
- Relationship
- Child, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- - PPO group NULL
- Coverage period
- 2023-10-01 to present
- Deductible
- $1,304.81 of $2,500.0052%
- Out-of-pocket maximum
- $3,501.33 of $7,500.0047%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 6315639594
- Network
- Out of network
- Rendering NPI
- 9548050241
- Location
- Austin, TX · TIN 17-4007347
- 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 | 93224 | Holter monitor, 48 hours | — | 1 | 1 | $335.00 | $150.75 | $75.00 | $75.75 | Paid |
| Totals | $335.00 | $150.75 | $75.00 | $75.75 | ||||||
Diagnoses (ICD-10-CM)
- 1. I50.9 Heart failure, unspecifiedprincipal
- 2. I25.10 Atherosclerotic heart disease of native coronary artery without angina
Claim header
- Patient account
- PA-567450
- 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-030395 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-16: - (PPO), effective 2023-10-01. | |
| Timely filing | Pass | Received 16 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 | 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. |
Evaluated 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Cardiovascular Associates2026-06-16 12:33
Patient seen for heart failure, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$335.00
Plan discount
$184.25
out-of-network allowance
Plan paid
$75.75
You may owe
$75.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
No other claims.
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
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
Approvedscenario: Clean
Clean claim, priced at contract rate.