CLM-2026-000111
Sunrise Community Hospital, Emergency Medicine. Service 2025-11-30 at emergency room (POS 23). Received 2026-07-02.
Member
Resolved through the identity graph
- Member
- Marilyn Nguyen
- Member ID
- UHC-42573-34
- Date of birth
- 1982-03-21
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-405400
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-1167
- Coverage period
- 2022-08-01 to present
- Deductible
- $431.55 of $500.0086%
- Out-of-pocket maximum
- $590.95 of $1,500.0039%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 2310065109
- Network
- In network
- Rendering NPI
- 2310065109
- Location
- Mesa, AZ · TIN 51-3085459
- Authorisation / referral
- none / REF979184
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 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $1,000.00 | $550.00 | — | — | DeniedCO29 |
| Totals | $1,000.00 | $550.00 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. R55 Syncope and collapse
- 3. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- Patient account
- PA-259950
- 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-031549 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-11-30: CORE-HMO (HMO), effective 2022-08-01. | |
| Timely filing | Fail | CO29 | Received 214 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Community Hospital (2310065109). | |
| 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 Community Hospital2025-11-30 10:41
Patient seen for unspecified abdominal pain.
- SystemSystem: Claims system2026-07-02 04:33
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-07-02 13:38
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-259950.pdf5 pages
Itemised statement totalling $1000.00 across 1 line.
- Er reported_report_PA-259950.pdf2 pages
Emergency department record: triage acuity 4, chief complaint unspecified abdominal pain.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 214 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
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
Received after the timely-filing limit.