CLM-2026-007037
Unity Community Hospital, Emergency Medicine. Service 2026-07-01 at emergency room (POS 23). Received 2026-07-28.
Member
Resolved through the identity graph
- Member
- Ana Santos
- Member ID
- UHC-93279-73
- Date of birth
- 1940-10-17
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-403349
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-7915
- Coverage period
- 2024-10-01 to present
- Deductible
- $630.05 of $1,000.0063%
- Out-of-pocket maximum
- $509.93 of $4,000.0013%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 2514292657
- Network
- In network
- Rendering NPI
- 2514292657
- Location
- Tampa, FL · TIN 44-4506990
- 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 | $1,531.00 | $842.05 | $350.00 | $492.05 | Paid |
| 2 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $245.00 | $134.75 | $0.00 | $134.75 | Paid |
| Totals | $1,776.00 | $976.80 | $350.00 | $626.80 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-323689
- 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-021362 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-01: SELECT-EPO (EPO), effective 2024-10-01. | |
| Timely filing | Pass | Received 27 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 (2514292657). | |
| 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 Hospital2026-07-01 18:47
Patient seen for unspecified abdominal pain.
Attachments
Documents received with the claim
- Itemized billitemized_PA-323689.pdf9 pages
Itemised statement totalling $1776.00 across 2 lines.
- Er reported_report_PA-323689.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 engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007038 | 2026-07-01 | Summit Regional Medical Center | $1,776.00 | 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.