CLM-2026-011524
Unity Community Hospital, Emergency Medicine. Service 2025-12-24 at emergency room (POS 23). Received 2026-02-01.
Member
Resolved through the identity graph
- Member
- Kathleen Butler
- Member ID
- UHC-38547-86
- Date of birth
- 1997-07-03
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-412850
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-2014
- Coverage period
- 2023-05-01 to present
- Deductible
- $390.23 of $1,000.0039%
- Out-of-pocket maximum
- $1,414.95 of $3,000.0047%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 5583357806
- Network
- In network
- Rendering NPI
- 5583357806
- Location
- Tempe, AZ · TIN 68-0325602
- Authorisation / referral
- none / REF903287
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 | $968.00 | $532.40 | $250.00 | $282.40 | Paid |
| 2 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,277.00 | $702.35 | $0.00 | $702.35 | Paid |
| Totals | $2,245.00 | $1,234.75 | $250.00 | $984.75 | ||||||
- 1. R55 Syncope and collapseprincipal
- Patient account
- PA-639548
- Frequency code
- 1 (original)
- Accident
- Yes
- 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-009402 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-12-24: CORE-HMO (HMO), effective 2023-05-01. | |
| Timely filing | Pass | Received 39 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 Unity Community Hospital (5583357806). | |
| 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: Unity Community Hospital2025-12-24 13:53
Patient seen for syncope and collapse.
Attachments
Documents received with the claim
- Itemized billitemized_PA-639548.pdf5 pages
Itemised statement totalling $2245.00 across 2 lines.
- Er reported_report_PA-639548.pdf3 pages
Emergency department record: triage acuity 2, chief complaint syncope and collapse.
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-034471 | 2026-07-02 | Meadow Family Practice | $334.00 | Approved |
| CLM-2026-011101 | 2026-07-18 | Summit Reference Lab | $253.00 | Needs review |
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.