CLM-2026-008767
Summit Regional Medical Center, Emergency Medicine. Service 2025-12-19 at emergency room (POS 23). Received 2026-01-17.
Member
Resolved through the identity graph
- Member
- Joshua Marshall
- Member ID
- UHC-44961-96
- Date of birth
- 1942-02-26
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-405989
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-7852
- Coverage period
- 2022-08-01 to present
- Deductible
- $1,001.14 of $1,500.0067%
- Out-of-pocket maximum
- $215.08 of $4,500.005%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 12 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 / REF593582
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 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $2,882.00 | $1,585.10 | $250.00 | $1,335.10 | Paid |
| 2 | 96374 rev 0260 | IV push, single drug | — | 1 | 2 | $226.00 | $124.30 | $0.00 | $124.30 | Paid |
| Totals | $3,108.00 | $1,709.40 | $250.00 | $1,459.40 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- Patient account
- PA-431880
- 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-004664 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-19: CORE-HMO (HMO), effective 2022-08-01. | |
| Timely filing | Pass | Received 29 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 Center2025-12-19 15:09
Patient seen for pneumonia, unspecified organism.
Attachments
Documents received with the claim
- Itemized billitemized_PA-431880.pdf4 pages
Itemised statement totalling $3108.00 across 2 lines.
- Er reported_report_PA-431880.pdf5 pages
Emergency department record: triage acuity 3, chief complaint pneumonia, unspecified organism.
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-2026-006792 | 2026-07-19 | Cornerstone Reference Lab | $94.00 | 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.