CLM-2026-011330
Summit Regional Medical Center, Emergency Medicine. Service 2025-12-10 at emergency room (POS 23). Received 2026-01-11.
Member
Resolved through the identity graph
- Member
- John Sims
- Member ID
- UHC-98485-42
- Date of birth
- 1979-06-09
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-414696
- Relationship
- Spouse, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-1667
- Coverage period
- 2025-11-01 to present
- Deductible
- $457.43 of $1,000.0046%
- Out-of-pocket maximum
- $152.30 of $2,000.008%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 3 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 | $933.00 | $513.15 | $150.00 | $363.15 | Paid |
| 2 | 96374 rev 0260 | IV push, single drug | 25 | 1 | 1 | $237.00 | $130.35 | $0.00 | $130.35 | Paid |
| Totals | $1,170.00 | $643.50 | $150.00 | $493.50 | ||||||
- 1. S93.401A Sprain of unspecified ligament of right ankle, initial encounterprincipal
- 2. J18.9 Pneumonia, unspecified organism
- 3. R07.9 Chest pain, unspecified
- Patient account
- PA-329712
- 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-003473 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-10: MEDICARE-ADV-B (MA), effective 2025-11-01. | |
| Timely filing | Pass | Received 32 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 Center2025-12-10 12:32
Follow-up for sprain of unspecified ligament of right ankle, initial encounter. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-329712.pdf5 pages
Itemised statement totalling $1170.00 across 2 lines.
- Er reported_report_PA-329712.pdf4 pages
Emergency department record: triage acuity 2, chief complaint sprain of unspecified ligament of right ankle, initial encounter.
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-2026-017366 | 2026-08-28 | Mesa Family Practice | $55.00 | Needs review |
| CLM-2026-012517 | 2026-01-28 | Evergreen Counseling Center | $449.00 | 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.