CLM-2026-013676
Sunrise Community Hospital, Emergency Medicine. Service 2026-02-24 at emergency room (POS 23). Received 2026-03-13.
Member
Resolved through the identity graph
- Member
- Stephen Schmidt
- Member ID
- UHC-23662-24
- Date of birth
- 1948-08-13
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-413476
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-7475
- Coverage period
- 2025-11-01 to 2026-05-11
- Deductible
- $1,455.89 of $3,500.0042%
- Out-of-pocket maximum
- $2,929.32 of $7,000.0042%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 13 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 / 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 | $690.00 | $379.50 | $150.00 | $229.50 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 2 | $125.00 | $68.75 | $0.00 | $68.75 | Paid |
| 3 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $259.00 | $142.45 | $0.00 | $142.45 | Paid |
| Totals | $1,074.00 | $590.70 | $150.00 | $440.70 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- Patient account
- PA-377435
- 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-019306 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-24: - (PPO), effective 2025-11-01, terms 2026-05-11. | |
| 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 Hospital2026-02-24 15:23
Established patient presents with pneumonia, unspecified organism; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-377435.pdf4 pages
Itemised statement totalling $1074.00 across 3 lines.
- Er reported_report_PA-377435.pdf6 pages
Emergency department record: triage acuity 4, 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-2026-028771 | 2026-05-08 | Unity Digestive Health Center | $1,844.00 | Needs review |
| CLM-2026-018494 | 2026-02-06 | Pinecrest Behavioral Health | $206.00 | 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.