CLM-2026-008244
Summit Regional Medical Center, Emergency Medicine. Service 2026-04-02 at emergency room (POS 23). Received 2026-04-27.
Member
Resolved through the identity graph
- Member
- Ronald Thomas
- Member ID
- UHC-18112-04
- Date of birth
- 1999-03-07
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-430186
- Relationship
- Child, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-4407
- Coverage period
- 2023-11-01 to present
- Deductible
- $235.68 of $1,000.0024%
- Out-of-pocket maximum
- $1,804.26 of $4,000.0045%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 14 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 | $1,319.00 | $725.45 | $150.00 | $575.45 | Paid |
| 2 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $2,383.00 | $1,310.65 | $0.00 | $1,310.65 | Paid |
| 3 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $254.00 | $139.70 | $0.00 | $139.70 | Paid |
| Totals | $3,956.00 | $2,175.80 | $150.00 | $2,025.80 | ||||||
- 1. R55 Syncope and collapseprincipal
- Patient account
- PA-145543
- 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-018333 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-02: MEDICARE-ADV-A (MA), effective 2023-11-01. | |
| Timely filing | Pass | Received 25 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 Center2026-04-02 15:19
Follow-up for syncope and collapse. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-145543.pdf7 pages
Itemised statement totalling $3956.00 across 3 lines.
- Er reported_report_PA-145543.pdf5 pages
Emergency department record: triage acuity 2, chief complaint syncope and collapse.
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-008990 | 2026-03-29 | Northgate Reference Lab | $62.00 | 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.