CLM-2026-010223
Summit Regional Medical Center, Emergency Medicine. Service 2026-07-18 at emergency room (POS 23). Received 2026-08-15.
Member
Resolved through the identity graph
- Member
- Arthur Robertson
- Member ID
- UHC-01568-37
- Date of birth
- 1989-05-18
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-430576
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2008
- Coverage period
- 2021-03-01 to present
- Deductible
- $2,066.13 of $3,500.0059%
- Out-of-pocket maximum
- $3,761.17 of $10,500.0036%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 22 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 | $246.00 | $135.30 | $135.30 | $0.00 | Paid |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $740.00 | $407.00 | $0.00 | $407.00 | Paid |
| 3 | 96374 rev 0260 | IV push, single drug | — | 1 | 2 | $234.00 | $128.70 | $0.00 | $128.70 | Paid |
| Totals | $1,220.00 | $671.00 | $135.30 | $535.70 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. R55 Syncope and collapse
- Patient account
- PA-925144
- 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-005446 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-07-18: N/A (PPO), effective 2021-03-01. | |
| Timely filing | Pass | Received 28 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 Center2026-07-18 09:53
Follow-up for pneumonia, unspecified organism. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-925144.pdf6 pages
Itemised statement totalling $1220.00 across 3 lines.
- Er reported_report_PA-925144.pdf3 pages
Emergency department record: triage acuity 2, chief complaint pneumonia, unspecified organism.
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-2026-017412 | 2026-02-01 | Lakeside Behavioral Health | $205.00 | Needs review |
| CLM-2026-017647 | 2026-02-02 | Sunrise Diagnostic Imaging | $1,861.00 | Needs review |
| CLM-2026-015345 | 2026-01-16 | Sunrise Clinical Laboratories | $67.00 | 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.