CLM-2026-030302
Sunrise Heart Institute, Cardiology. Service 2026-01-11 at outpatient hospital (POS 22). Received 2026-01-22.
Member
Resolved through the identity graph
- Member
- Lawrence Fuller
- Member ID
- UHC-49156-23
- Date of birth
- 2000-12-09
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-427218
- Relationship
- Spouse, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9427
- Coverage period
- 2021-05-01 to present
- Deductible
- $1,286.44 of $2,500.0051%
- Out-of-pocket maximum
- $1,175.20 of $7,500.0016%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 7885317132
- Network
- In network
- Rendering NPI
- 9643373928
- Location
- Mesa, AZ · TIN 11-9149520
- Authorisation / referral
- none / REF794306
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 | 93015 | Cardiovascular stress test | — | 1 | 1 | $459.00 | $252.45 | $252.45 | $0.00 | Paid |
| Totals | $459.00 | $252.45 | $252.45 | $0.00 | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. I25.10 Atherosclerotic heart disease of native coronary artery without angina
- 3. R07.9 Chest pain, unspecified
- Patient account
- PA-374865
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000439 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-11: CORE-HMO (HMO), effective 2021-05-01. | |
| Timely filing | Pass | Received 11 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 Institute2026-01-11 10:43
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-374865.pdf9 pages
Itemised statement totalling $459.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean 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.