CLM-2026-003732
Mesa Regional Medical Center, Emergency Medicine. Service 2026-02-22 at emergency room (POS 23). Received 2026-03-17.
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
- Mesa Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 3600007819
- Network
- Out of network
- Rendering NPI
- 5583357806 (Unity Community Hospital)
- Location
- Tampa, FL · TIN 90-5702951
- 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 | $74.25 | — | — | Review |
| Totals | $165.00 | $74.25 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. J18.9 Pneumonia, unspecified organism
- Patient account
- PA-149847
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 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 23 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-003731, billed by a different provider. Possible duplicate |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Mesa Regional Medical Center2026-02-22 13:36
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-03-17 05:23
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
Attachments
Documents received with the claim
- Itemized billitemized_PA-149847.pdf5 pages
Itemised statement totalling $165.00 across 1 line.
- Er reported_report_PA-149847.pdf5 pages
Emergency department record: triage acuity 3, chief complaint unspecified abdominal pain.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Duplicate check: Same member, date of service and procedures as CLM-2026-003731, billed by a different provider. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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-2026-003731 | 2026-02-22 | Unity Community Hospital | $165.00 | Approved |
| 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
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Different billing provider; separately payable.