CLM-2026-010090
Summit Regional Medical Center, Emergency Medicine. Service 2026-09-29 at emergency room (POS 23). Received 2026-10-12.
Member
Resolved through the identity graph
- Member
- Fatima Ford
- Member ID
- UHC-30941-57
- Date of birth
- 1992-05-16
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-415105
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2926
- Coverage period
- 2025-01-01 to present
- Deductible
- $1,970.65 of $2,500.0079%
- Out-of-pocket maximum
- $481.64 of $10,000.005%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 1 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 / 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 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $790.00 | $434.50 | — | — | PendedIDQ |
| Totals | $790.00 | $434.50 | — | — | ||||||
- 1. R55 Syncope and collapseprincipal
- Patient account
- PA-227610
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-002013; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-09-29: NULL (PPO), effective 2025-01-01. | |
| Timely filing | Pass | Received 13 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 Center2026-09-29 09:01
Follow-up for syncope and collapse. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-227610.pdf2 pages
Itemised statement totalling $790.00 across 1 line.
- Er reported_report_PA-227610.pdf6 pages
Emergency department record: triage acuity 4, chief complaint syncope and collapse.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-002013; payment withheld until the identity is confirmed.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.