CLM-2026-008112
Summit Regional Medical Center, Emergency Medicine. Service 2026-03-10 at emergency room (POS 23). Received 2026-03-23.
Member
Resolved through the identity graph
- Member
- Laura Sullivan
- Member ID
- UHC-42409-28
- Date of birth
- 1974-11-11
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-400799
- Relationship
- Child, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-0680
- Coverage period
- 2023-07-01 to present
- Deductible
- $120.30 of $1,000.0012%
- Out-of-pocket maximum
- $759.10 of $4,000.0019%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 1269847210
- Network
- In network
- Rendering NPI
- 1269847210
- Location
- Mesa, AZ · TIN 62-8021640
- 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 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $219.00 | $120.45 | $120.45 | $0.00 | Paid |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $734.00 | $403.70 | $0.00 | $403.70 | Paid |
| Totals | $953.00 | $524.15 | $120.45 | $403.70 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-443019
- 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-000220 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-03-10: N/A (PPO), effective 2023-07-01. | |
| Timely filing | Pass | Received 13 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 (1269847210). | |
| 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 Center2026-03-10 16:35
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-443019.pdf7 pages
Itemised statement totalling $953.00 across 2 lines.
- Er reported_report_PA-443019.pdf5 pages
Emergency department record: triage acuity 3, chief complaint chest pain, unspecified.
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-2026-010589 | 2025-12-17 | Valley Imaging Center | $1,531.00 | Approved |
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.