CLM-2026-000219
Summit Regional Medical Center, Emergency Medicine. Service 2026-05-01 at emergency room (POS 23). Received 2026-06-09.
Member
Resolved through the identity graph
- Member
- Patricia Gomez
- Member ID
- UHC-71807-52
- Date of birth
- 1940-10-24
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-408751
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8072
- Coverage period
- 2021-04-01 to present
- Deductible
- $227.10 of $500.0045%
- Out-of-pocket maximum
- $609.21 of $1,500.0041%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 1269847210
- Network
- In network
- Rendering NPI
- 1269847210
- Location
- Mesa, AZ · TIN 62-8021640
- Authorisation / referral
- none / none
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 | $1,080.00 | $594.00 | $350.00 | $244.00 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $123.00 | $67.65 | $0.00 | $67.65 | Paid |
| Totals | $1,203.00 | $661.65 | $350.00 | $311.65 | ||||||
- 1. R55 Syncope and collapseprincipal
- 2. R07.9 Chest pain, unspecified
- 3. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- Patient account
- PA-146706
- 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-005382 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-05-01: SELECT-EPO (EPO), effective 2021-04-01. | |
| Timely filing | Pass | Received 39 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 Summit Regional Medical Center (1269847210). | |
| 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: Summit Regional Medical Center2026-05-01 14:18
Patient seen for syncope and collapse.
Attachments
Documents received with the claim
- Itemized billitemized_PA-146706.pdf4 pages
Itemised statement totalling $1203.00 across 2 lines.
- Er reported_report_PA-146706.pdf6 pages
Emergency department record: triage acuity 2, chief complaint syncope and collapse.
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-000220 | 2026-05-01 | Summit Regional Medical Center | $1,203.00 | Denied |
| CLM-2026-009744 | 2026-02-26 | Lakeside Orthopedic Specialists | $255.00 | Approved |
| CLM-2026-019769 | 2026-01-10 | Harbor Digestive Health Center | $3,507.00 | Denied |
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.