CLM-2026-002343
Unity Community Hospital, Emergency Medicine. Service 2026-08-27 at emergency room (POS 23). Received 2026-09-27.
Member
Resolved through the identity graph
- Member
- Mateo Weber
- Member ID
- UHC-71512-78
- Date of birth
- 1955-04-19
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-410982
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3239
- Coverage period
- 2023-05-01 to present
- Deductible
- $1,337.79 of $2,500.0054%
- Out-of-pocket maximum
- $2,890.37 of $7,500.0039%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 5583357806
- Network
- In network
- Rendering NPI
- 5583357806
- Location
- Tempe, AZ · TIN 68-0325602
- 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 | $1,178.00 | $647.90 | $150.00 | $497.90 | Paid |
| 2 | 96374 rev 0260 | IV push, single drug | 25 | 1 | 2 | $217.00 | $119.35 | $0.00 | $119.35 | Paid |
| 3 | 99283 rev 0450 | Emergency department visit, moderate severity | 25 | 1 | 1,2 | $939.00 | $516.45 | $0.00 | $516.45 | Paid |
| Totals | $2,334.00 | $1,283.70 | $150.00 | $1,133.70 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. R55 Syncope and collapse
- 3. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- Patient account
- PA-618610
- 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-010338 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-27: OPTIONS-PPO (PPO), effective 2023-05-01. | |
| Timely filing | Pass | Received 31 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 Unity Community Hospital (5583357806). | |
| 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: Unity Community Hospital2026-08-27 10:14
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-618610.pdf4 pages
Itemised statement totalling $2334.00 across 3 lines.
- Er reported_report_PA-618610.pdf2 pages
Emergency department record: triage acuity 4, chief complaint unspecified abdominal pain.
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
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.