CLM-2026-000636
Sunrise Community Hospital, Emergency Medicine. Service 2026-08-12 at emergency room (POS 23). Received 2026-08-30.
Member
Resolved through the identity graph
- Member
- Brandon Rice
- Member ID
- UHC-75050-61
- Date of birth
- 1986-03-14
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-402653
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-5894
- Coverage period
- 2023-03-01 to present
- Deductible
- $601.59 of $3,500.0017%
- Out-of-pocket maximum
- $6,789.13 of $14,000.0048%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 19 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 / 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 | $1,574.00 | $865.70 | $150.00 | $715.70 | Paid |
| 2 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $2,195.00 | $1,207.25 | $0.00 | $1,207.25 | Paid |
| Totals | $3,769.00 | $2,072.95 | $150.00 | $1,922.95 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-359717
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-018672 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-08-12: N/A (PPO), effective 2023-03-01. | |
| Timely filing | Pass | Received 18 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 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 Hospital2026-08-12 16:23
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-359717.pdf3 pages
Itemised statement totalling $3769.00 across 2 lines.
- Er reported_report_PA-359717.pdf4 pages
Emergency department record: triage acuity 4, chief complaint chest pain, unspecified.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-006479 | 2026-07-31 | Lakeside Imaging Center | $2,448.00 | Denied |
| CLM-2026-006478 | 2026-07-31 | Lakeside Imaging Center | $2,448.00 | 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.