CLM-2026-009751
Summit Regional Medical Center, Emergency Medicine. Service 2026-04-13 at emergency room (POS 23). Received 2026-04-30.
Member
Resolved through the identity graph
- Member
- Teresa Myers
- Member ID
- UHC-67569-91
- Date of birth
- 1966-05-12
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-410411
- Relationship
- Spouse, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7781
- Coverage period
- 2021-05-01 to present
- Deductible
- $201.51 of $500.0040%
- Out-of-pocket maximum
- $387.77 of $1,000.0039%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 18 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $250.00 | $137.50 | $137.50 | $0.00 | Paid |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | 25 | 1 | 1 | $724.00 | $398.20 | $0.00 | $398.20 | Paid |
| Totals | $974.00 | $535.70 | $137.50 | $398.20 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-913217
- 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-015023 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-13: NULL (PPO), effective 2021-05-01. | |
| Timely filing | Pass | Received 17 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 Center2026-04-13 11:00
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-913217.pdf3 pages
Itemised statement totalling $974.00 across 2 lines.
- Er reported_report_PA-913217.pdf4 pages
Emergency department record: triage acuity 2, chief complaint unspecified abdominal pain.
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-2026-033527 | 2026-02-04 | Desert Medical Group | $289.00 | 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.