CLM-2026-009969
Unity Community Hospital, Emergency Medicine. Service 2026-07-14 at emergency room (POS 23). Received 2026-07-31.
Member
Resolved through the identity graph
- Member
- Maria Dominguez
- Member ID
- UHC-24070-78
- Date of birth
- 1997-08-23
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-400388
- Relationship
- Child, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-3756
- Coverage period
- 2023-01-01 to present
- Deductible
- $378.58 of $500.0076%
- Out-of-pocket maximum
- $228.36 of $1,500.0015%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 2514292657
- Network
- In network
- Rendering NPI
- 2514292657
- Location
- Tampa, FL · TIN 44-4506990
- Authorisation / referral
- none / REF616263
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 | $160.00 | $88.00 | $88.00 | $0.00 | Paid |
| 2 | 96374 rev 0260 | IV push, single drug | — | 1 | 2 | $201.00 | $110.55 | $0.00 | $110.55 | Paid |
| 3 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,520.00 | $836.00 | $0.00 | $836.00 | Paid |
| Totals | $1,881.00 | $1,034.55 | $88.00 | $946.55 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-588341
- 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-012901 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-14: NAVIGATE-HMO (HMO), effective 2023-01-01. | |
| 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 Unity Community Hospital (2514292657). | |
| 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: Unity Community Hospital2026-07-14 17:44
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-588341.pdf4 pages
Itemised statement totalling $1881.00 across 3 lines.
- Er reported_report_PA-588341.pdf3 pages
Emergency department record: triage acuity 4, chief complaint chest pain, unspecified.
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-2026-022022 | 2026-07-12 | Cornerstone Internal Medicine Associates | $89.00 | Approved |
| CLM-2026-013238 | 2026-02-25 | Unity Imaging Center | $2,100.00 | Denied |
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.