CLM-2026-004081
Summit Regional Medical Center, Emergency Medicine. Service 2025-12-02 at emergency room (POS 23). Received 2026-01-11.
Member
Resolved through the identity graph
- Member
- Jonathan Simmons
- Member ID
- UHC-03464-95
- Date of birth
- 1988-05-11
- Identity
- Verified4 records, confidence 0.98
- Claim record
- CLMCLM-430968
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-6793
- Coverage period
- 2024-08-01 to present
- Deductible
- $586.85 of $1,500.0039%
- Out-of-pocket maximum
- $1,404.02 of $3,000.0047%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 7959926214
- Network
- In network
- Rendering NPI
- 7959926214
- Location
- Mesa, AZ · TIN 13-8570749
- 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 | $1,388.00 | $763.40 | $250.00 | $513.40 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $248.00 | $136.40 | $0.00 | $136.40 | Paid |
| Totals | $1,636.00 | $899.80 | $250.00 | $649.80 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-612444
- 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-003398 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2025-12-02: - (PPO), effective 2024-08-01. | |
| Timely filing | Pass | Received 40 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 Summit Regional Medical Center (7959926214). | |
| 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: Summit Regional Medical Center2025-12-02 13:40
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-01-11 01:17
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-01-11 11:51
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-612444.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
- Itemized billitemized_PA-612444.pdf6 pages
Itemised statement totalling $1636.00 across 2 lines.
- Er reported_report_PA-612444.pdf6 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
Authorisation must be confirmed with UM before payment.