CLM-2026-001998
Canyon Community Hospital, Emergency Medicine. Service 2026-08-29 at emergency room (POS 23). Received 2026-09-24.
Member
Resolved through the identity graph
- Member
- Lori Dixon
- Member ID
- UHC-20645-16
- Date of birth
- 1939-09-23
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-400896
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-3238
- Coverage period
- 2024-02-01 to 2026-02-26
- Deductible
- $2,594.81 of $3,500.0074%
- Out-of-pocket maximum
- $4,560.36 of $10,500.0043%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 9109847134
- Network
- Out of network
- Rendering NPI
- 9109847134
- Location
- Phoenix, AZ · TIN 21-6618841
- 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 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $2,519.00 | $1,385.45 | — | — | DeniedCO27 |
| Totals | $2,519.00 | $1,385.45 | — | — | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-453094
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-021946 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-29 is after coverage terminated on 2026-02-26. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 26 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 | Review | NET | Out-of-network emergency visit. Payable at the in-network level if the prudent-layperson standard is met; review the ED record. Out-of-network provider |
| 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: Canyon Community Hospital2026-08-29 17:33
Patient seen for pneumonia, unspecified organism.
- SystemSystem: Claims system2026-09-24 03:06
Attachments
Documents received with the claim
- Itemized billitemized_PA-453094.pdf6 pages
Itemised statement totalling $2519.00 across 1 line.
- Er reported_report_PA-453094.pdf6 pages
Emergency department record: triage acuity 3, chief complaint pneumonia, unspecified organism.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-29 is after coverage terminated on 2026-02-26. Provider network: Out-of-network emergency visit. Payable at the in-network level if the prudent-layperson standard is met; review the ED record.
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
Service after coverage termination.