CLM-2026-033915
Sunrise Cardiovascular Associates, Cardiology. Service 2026-05-10 at office (POS 11). Received 2026-05-22.
Member
Resolved through the identity graph
- Member
- James Banks
- Member ID
- UHC-39366-98
- Date of birth
- 1999-03-22
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-427089
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-0107
- Coverage period
- 2023-10-01 to present
- Deductible
- $100.07 of $500.0020%
- Out-of-pocket maximum
- $684.26 of $2,000.0034%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 6315639594
- Network
- Out of network
- Rendering NPI
- 1334335258
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $338.00 | $152.10 | — | — | DeniedCO204 |
| 2 | 93224 | Holter monitor, 48 hours | — | 1 | 1 | $456.00 | $205.20 | — | — | DeniedCO204 |
| Totals | $794.00 | $357.30 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-911121
- 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-008230 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-10: SELECT-EPO (EPO), effective 2023-10-01. | |
| Timely filing | Pass | Received 12 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 | Fail | CO204 | Billing provider 6315639594 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Associates2026-05-10 18:41
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-05-22 00:57
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 6315639594 is out of network and the EPO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-013053 | 2026-06-01 | Mesa Dermatology Clinic | $155.00 | Approved |
| CLM-2026-033089 | 2026-01-11 | Riverside Imaging Center | $373.00 | Approved |
| CLM-2026-023402 | 2025-12-18 | Evergreen Family Practice | $409.00 | 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
No out-of-network benefit on this plan.