CLM-2026-013120
Unity Community Hospital, Emergency Medicine. Service 2026-08-28 at emergency room (POS 23). Received 2026-09-11.
Member
Resolved through the identity graph
- Member
- Camila Martinez
- Member ID
- UHC-83618-98
- Date of birth
- 1995-03-24
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-402269
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-1010
- Coverage period
- 2022-07-01 to present
- Deductible
- $645.14 of $1,500.0043%
- Out-of-pocket maximum
- $1,359.30 of $3,000.0045%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 1 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 / 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 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,237.00 | $680.35 | $350.00 | $330.35 | Paid |
| 2 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $2,152.00 | $1,183.60 | $0.00 | $1,183.60 | Paid |
| Totals | $3,389.00 | $1,863.95 | $350.00 | $1,513.95 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. R55 Syncope and collapse
- 3. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- Patient account
- PA-165517
- 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-032157 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-28: NULL (PPO), effective 2022-07-01. | |
| Timely filing | Pass | Received 14 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 Hospital2026-08-28 10:07
Patient seen for pneumonia, unspecified organism.
Attachments
Documents received with the claim
- Itemized billitemized_PA-165517.pdf8 pages
Itemised statement totalling $3389.00 across 2 lines.
- Er reported_report_PA-165517.pdf2 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017174 | 2026-04-24 | Lakeside Endocrine Associates | $228.00 | 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.