CLM-2026-010174
Sunrise Community Hospital, Emergency Medicine. Service 2025-12-07 at emergency room (POS 23). Received 2026-01-21.
Member
Resolved through the identity graph
- Member
- Brandon Sandoval
- Member ID
- UHC-30571-89
- Date of birth
- 1947-03-07
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-410512
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4451
- Coverage period
- 2023-02-01 to present
- Deductible
- $429.77 of $3,500.0012%
- Out-of-pocket maximum
- $2,759.28 of $7,000.0039%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 22 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 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $166.00 | $91.30 | $91.30 | $0.00 | Paid |
| 2 | 99284 rev 0450 | Emergency department visit, high severity | 25 | 1 | 1,2 | $1,648.00 | $906.40 | $0.00 | $906.40 | Paid |
| 3 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1,2 | $133.00 | $73.15 | $0.00 | $73.15 | Paid |
| Totals | $1,947.00 | $1,070.85 | $91.30 | $979.55 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. R55 Syncope and collapse
- Patient account
- PA-649954
- 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-006250 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-07: SELECT-EPO (EPO), effective 2023-02-01. | |
| Timely filing | Pass | Received 45 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 Hospital2025-12-07 10:49
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-649954.pdf4 pages
Itemised statement totalling $1947.00 across 3 lines.
- Er reported_report_PA-649954.pdf5 pages
Emergency department record: triage acuity 3, 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 engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021483 | 2026-04-14 | Unity Cardiovascular Associates | $2,294.00 | Needs review |
| CLM-2026-020467 | 2026-03-19 | Canyon Medical Group | $424.00 | 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.