CLM-2026-011118
Sunrise Community Hospital, Emergency Medicine. Service 2026-01-16 at emergency room (POS 23). Received 2026-02-02.
Member
Resolved through the identity graph
- Member
- Mary Li
- Member ID
- UHC-75835-27
- Date of birth
- 1962-12-14
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-424964
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-4336
- Coverage period
- 2023-11-01 to present
- Deductible
- $115.95 of $500.0023%
- Out-of-pocket maximum
- $53.37 of $2,000.003%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 4 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 / REF259239
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 | $219.00 | $120.45 | $120.45 | $0.00 | Paid |
| Totals | $219.00 | $120.45 | $120.45 | $0.00 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. R55 Syncope and collapse
- Patient account
- PA-116376
- 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-009718 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-16: CORE-HMO (HMO), effective 2023-11-01. | |
| 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 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 Hospital2026-01-16 10:54
Follow-up for pneumonia, unspecified organism. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-116376.pdf3 pages
Itemised statement totalling $219.00 across 1 line.
- Er reported_report_PA-116376.pdf4 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 engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
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.