CLM-2026-008547
Summit Regional Medical Center, Emergency Medicine. Service 2026-07-07 at emergency room (POS 23). Received 2026-08-11.
Member
Resolved through the identity graph
- Member
- Sharon Alexander
- Member ID
- UHC-08955-29
- Date of birth
- 1992-04-27
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-424484
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group NULL
- Coverage period
- 2021-08-01 to present
- Deductible
- $1,781.37 of $2,500.0071%
- Out-of-pocket maximum
- $1,227.96 of $5,000.0025%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 8 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 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,095.00 | $602.25 | $250.00 | $352.25 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 2 | $128.00 | $70.40 | $0.00 | $70.40 | Paid |
| Totals | $1,223.00 | $672.65 | $250.00 | $422.65 | ||||||
- 1. R55 Syncope and collapseprincipal
- 2. R10.9 Unspecified abdominal pain
- 3. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- Patient account
- PA-868201
- 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-008223 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-07: SELECT-EPO (EPO), effective 2021-08-01. | |
| Timely filing | Pass | Received 35 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 Center2026-07-07 18:33
Established patient presents with syncope and collapse; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-868201.pdf6 pages
Itemised statement totalling $1223.00 across 2 lines.
- Er reported_report_PA-868201.pdf3 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-2026-024348 | 2026-08-21 | Sunrise Medical Group | $101.00 | Approved |
| CLM-2026-020778 | 2026-05-22 | Sunrise Physical Therapy | $7,767.00 | 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.