CLM-2026-008646
Summit Regional Medical Center, Emergency Medicine. Service 2026-03-10 at emergency room (POS 23). Received 2026-04-20.
Member
Resolved through the identity graph
- Member
- Alexis Morrison
- Member ID
- UHC-65543-73
- Date of birth
- 1949-03-08
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-430633
- Relationship
- Child, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8178
- Coverage period
- 2024-09-01 to present
- Deductible
- $1,018.47 of $1,500.0068%
- Out-of-pocket maximum
- $197.57 of $3,000.007%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 15 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 | $147.00 | $80.85 | $80.85 | $0.00 | Paid |
| 2 | 99284 rev 0450 | Emergency department visit, high severity | 25 | 1 | 1 | $1,693.00 | $931.15 | $0.00 | $931.15 | Paid |
| Totals | $1,840.00 | $1,012.00 | $80.85 | $931.15 | ||||||
- 1. R55 Syncope and collapseprincipal
- 2. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- 3. R07.9 Chest pain, unspecified
- Patient account
- PA-831431
- 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-026769 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-10: UNKNOWN (PPO), effective 2024-09-01. | |
| Timely filing | Pass | Received 41 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 15:18
Follow-up for syncope and collapse. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-831431.pdf6 pages
Itemised statement totalling $1840.00 across 2 lines.
- Er reported_report_PA-831431.pdf3 pages
Emergency department record: triage acuity 4, 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 engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024687 | 2026-08-18 | Lakeside Medical Group | $183.00 | 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.