CLM-2026-000403
Summit Regional Medical Center, Emergency Medicine. Service 2026-07-09 at emergency room (POS 23). Received 2026-07-16.
Member
Resolved through the identity graph
- Member
- Lori Jordan
- Member ID
- UHC-12979-70
- Date of birth
- 1985-05-24
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-411391
- Relationship
- Child, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3687
- Coverage period
- 2023-08-01 to present
- Deductible
- $1,669.24 of $3,500.0048%
- Out-of-pocket maximum
- $2,941.85 of $7,000.0042%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 7959926214
- Network
- In network
- Rendering NPI
- 7959926214
- Location
- Mesa, AZ · TIN 13-8570749
- 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 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,105.00 | $607.75 | $250.00 | $357.75 | Paid |
| Totals | $1,105.00 | $607.75 | $250.00 | $357.75 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- Patient account
- PA-920871
- 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-019305 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-07-09: OPTIONS-PPO (PPO), effective 2023-08-01. | |
| Timely filing | Pass | Received 7 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 (7959926214). | |
| 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 Center2026-07-09 17:37
Follow-up for pneumonia, unspecified organism. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-920871.pdf9 pages
Itemised statement totalling $1105.00 across 1 line.
- Er reported_report_PA-920871.pdf2 pages
Emergency department record: triage acuity 2, chief complaint pneumonia, unspecified organism.
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-2026-002758 | 2026-05-20 | Lakeside Internal Medicine Associates | $130.00 | Approved |
| CLM-2026-012583 | 2026-03-23 | Riverside Clinical Laboratories | $62.00 | Approved |
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.