CLM-2026-003184
Unity Community Hospital, Emergency Medicine. Service 2026-06-14 at emergency room (POS 23). Received 2026-09-17.
Member
Resolved through the identity graph
- Member
- Scott Gibson
- Member ID
- UHC-52419-70
- Date of birth
- 2004-06-02
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-425453
- Relationship
- Spouse, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4659
- Coverage period
- 2025-07-01 to present
- Deductible
- $1,752.00 of $3,500.0050%
- Out-of-pocket maximum
- $2,385.54 of $10,500.0023%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 21 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 | $1,493.00 | $821.15 | — | — | DeniedCO29 |
| Totals | $1,493.00 | $821.15 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. J18.9 Pneumonia, unspecified organism
- Patient account
- PA-616224
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-011596 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-14: - (PPO), effective 2025-07-01. | |
| Timely filing | Fail | CO29 | Received 95 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Hospital2026-06-14 16:33
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-17 05:51
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-09-17 09:32
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-616224.pdf8 pages
Itemised statement totalling $1493.00 across 1 line.
- Er reported_report_PA-616224.pdf4 pages
Emergency department record: triage acuity 3, chief complaint chest pain, unspecified.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 95 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025209 | 2026-10-01 | Desert Family Practice | $475.00 | Approved |
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
Received after the timely-filing limit.