CLM-2026-003731
Unity Community Hospital, Emergency Medicine. Service 2026-02-22 at emergency room (POS 23). Received 2026-03-11.
Member
Resolved through the identity graph
- Member
- Victoria Schmidt
- Member ID
- UHC-00189-24
- Date of birth
- 1988-06-12
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-406232
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-5352
- Coverage period
- 2025-03-01 to present
- Deductible
- $349.61 of $1,000.0035%
- Out-of-pocket maximum
- $1,690.68 of $4,000.0042%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 0 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $165.00 | $90.75 | $90.75 | $0.00 | Paid |
| Totals | $165.00 | $90.75 | $90.75 | $0.00 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. J18.9 Pneumonia, unspecified organism
- Patient account
- PA-944031
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-010443 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-22: MEDICARE-ADV-A (MA), effective 2025-03-01. | |
| Timely filing | Pass | Received 17 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 Hospital2026-02-22 17:58
Patient seen for unspecified abdominal pain.
Attachments
Documents received with the claim
- Itemized billitemized_PA-944031.pdf4 pages
Itemised statement totalling $165.00 across 1 line.
- Er reported_report_PA-944031.pdf3 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 engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032784 | 2026-06-19 | Lakeside Internal Medicine Associates | $319.00 | Approved |
| CLM-2026-025020 | 2026-06-17 | Unity Reference Lab | $130.00 | Approved |
| CLM-2026-000087 | 2026-05-24 | Riverside Internal Medicine Associates | $199.00 | Approved |
| CLM-2026-003732 | 2026-02-22 | Mesa Regional Medical Center | $165.00 | Needs review |
| CLM-2026-010923 | 2026-01-04 | Evergreen Rehabilitation Center | $270.00 | Needs review |
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.