Professional claim · CMS-1500 · Paper
CLM-2026-033485
Sunrise Cardiovascular Associates, Cardiology. Service 2026-03-01 at office (POS 11). Received 2026-03-03.
ApprovedOut of network
Billed
$383.00
1 line
Allowed
$172.35
contract rate applied
Plan pays
$97.35
approved
Member owes
$75.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Paul Riley
- Member ID
- UHC-16469-58
- Date of birth
- 1973-02-14
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-420272
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-5564
- Coverage period
- 2022-11-01 to present
- Deductible
- $2,142.41 of $2,500.0086%
- Out-of-pocket maximum
- $1,602.13 of $7,500.0021%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 6315639594
- Network
- Out of network
- Rendering NPI
- 5243351264
- 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 | $383.00 | $172.35 | $75.00 | $97.35 | Paid |
| Totals | $383.00 | $172.35 | $75.00 | $97.35 | ||||||
Diagnoses (ICD-10-CM)
- 1. R07.9 Chest pain, unspecifiedprincipal
Claim header
- Patient account
- PA-466279
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-015117 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-01: OPTIONS-PPO (PPO), effective 2022-11-01. | |
| Timely filing | Pass | Received 2 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 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Cardiovascular Associates2026-03-01 14:46
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$383.00
Plan discount
$210.65
out-of-network allowance
Plan paid
$97.35
You may owe
$75.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016222 | 2026-05-14 | Pinecrest Medical Group | $187.00 | Approved |
| CLM-2026-023876 | 2026-02-27 | Mesa Bone and Joint Center | $8,006.00 | Approved |
| CLM-2026-008437 | 2026-02-01 | Meadow Physical Therapy | $5,036.00 | Needs review |
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.