CLM-2026-002165
Sunrise Community Hospital, Emergency Medicine. Service 2026-02-25 at emergency room (POS 23). Received 2026-03-01.
Member
Resolved through the identity graph
- Member
- Jessica Snyder
- Member ID
- UHC-92417-51
- Date of birth
- 1964-07-06
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-413038
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-3834
- Coverage period
- 2025-11-01 to present
- Deductible
- $842.25 of $2,500.0034%
- Out-of-pocket maximum
- $1,244.27 of $5,000.0025%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 2411187117
- Network
- Out of network
- Rendering NPI
- 2411187117
- Location
- Tempe, AZ · TIN 19-3902018
- 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $235.00 | $129.25 | — | — | Review |
| Totals | $235.00 | $129.25 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-142763
- Frequency code
- 1 (original)
- Accident
- Yes
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-016632 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-25: SELECT-EPO (EPO), effective 2025-11-01. | |
| Timely filing | Pass | Received 4 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: Sunrise Community Hospital2026-02-25 17:47
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled. Patient presented to the nearest emergency department with acute symptoms; care could not safely be delayed to reach an in-network facility.
- SystemSystem: Claims system2026-03-01 00:13
Out-of-network emergency visit. Emergency services are payable at the in-network level when the prudent-layperson standard is met.
Attachments
Documents received with the claim
- Itemized billitemized_PA-142763.pdf9 pages
Itemised statement totalling $235.00 across 1 line.
- Er reported_report_PA-142763.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 engineReview2026-10-22 12:44Provider 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029827 | 2026-02-27 | Sunrise Dermatology Clinic | $232.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Emergency: payable at in-network level.