CLM-2026-009298
Sunrise Community Hospital, Emergency Medicine. Service 2026-02-18 at emergency room (POS 23). Received 2026-03-08.
Member
Resolved through the identity graph
- Member
- Yuki Herrera
- Member ID
- UHC-52366-24
- Date of birth
- 1996-01-20
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-402663
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6922
- Coverage period
- 2024-01-01 to present
- Deductible
- $699.88 of $1,500.0047%
- Out-of-pocket maximum
- $660.47 of $3,000.0022%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 2310065109
- Network
- In network
- Rendering NPI
- 2310065109
- Location
- Mesa, AZ · TIN 51-3085459
- 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 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $1,815.00 | $998.25 | $350.00 | $648.25 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $185.00 | $101.75 | $0.00 | $101.75 | Paid |
| Totals | $2,000.00 | $1,100.00 | $350.00 | $750.00 | ||||||
- 1. R55 Syncope and collapseprincipal
- Patient account
- PA-549178
- 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-000768 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-18: CHOICE-PLUS-PPO (PPO), effective 2024-01-01. | |
| Timely filing | Pass | Received 18 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 Sunrise Community Hospital (2310065109). | |
| 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: Sunrise Community Hospital2026-02-18 17:36
Patient seen for syncope and collapse.
Attachments
Documents received with the claim
- Itemized billitemized_PA-549178.pdf6 pages
Itemised statement totalling $2000.00 across 2 lines.
- Er reported_report_PA-549178.pdf6 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-2026-026698 | 2026-07-04 | Summit Regional Medical Center | $5,036.00 | Approved |
| CLM-2026-015788 | 2026-03-20 | Northgate Internal Medicine Associates | $557.00 | Approved |
| CLM-2026-011863 | 2025-12-23 | Desert Medical Group | $3,554.00 | 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.