CLM-2026-003445
Unity Community Hospital, Emergency Medicine. Service 2026-04-26 at emergency room (POS 23). Received 2026-05-11.
Member
Resolved through the identity graph
- Member
- Keith Ramirez
- Member ID
- UHC-39559-25
- Date of birth
- 1954-06-19
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-411937
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-3066
- Coverage period
- 2022-06-01 to present
- Deductible
- $267.50 of $3,500.008%
- Out-of-pocket maximum
- $3,006.69 of $7,000.0043%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 13 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 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $835.00 | $459.25 | $350.00 | $109.25 | Paid |
| 2 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1,2 | $3,170.00 | $1,743.50 | $0.00 | $1,743.50 | Paid |
| 3 | 96374 rev 0260 | IV push, single drug | — | 1 | 1,2 | $180.00 | $99.00 | $0.00 | $99.00 | Paid |
| Totals | $4,185.00 | $2,301.75 | $350.00 | $1,951.75 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-104885
- 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-026354 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-04-26: MEDICARE-ADV-B (MA), effective 2022-06-01. | |
| Timely filing | Pass | Received 15 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 Hospital2026-04-26 17:59
Patient seen for unspecified abdominal pain.
Attachments
Documents received with the claim
- Itemized billitemized_PA-104885.pdf2 pages
Itemised statement totalling $4185.00 across 3 lines.
- Er reported_report_PA-104885.pdf5 pages
Emergency department record: triage acuity 3, 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-034197 | 2026-05-20 | Heritage Family Practice | $235.00 | Approved |
| CLM-2026-006977 | 2026-05-14 | Cornerstone Bone and Joint Center | $8,819.00 | Denied |
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.