CLM-2026-013874
Unity Community Hospital, Emergency Medicine. Service 2026-06-26 at emergency room (POS 23). Received 2026-08-04.
Member
Resolved through the identity graph
- Member
- Mariana Williamson
- Member ID
- UHC-03230-89
- Date of birth
- 1971-12-27
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-409136
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-9022
- Coverage period
- 2025-12-01 to 2026-06-05
- Deductible
- $373.67 of $2,500.0015%
- Out-of-pocket maximum
- $2,494.92 of $7,500.0033%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 2514292657
- Network
- In network
- Rendering NPI
- 2514292657
- Location
- Tampa, FL · TIN 44-4506990
- 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 | $628.00 | $345.40 | — | — | DeniedCO27 |
| 2 | 96374 rev 0260 | IV push, single drug | 25 | 1 | 1,2 | $208.00 | $114.40 | — | — | DeniedCO27 |
| Totals | $836.00 | $459.80 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. J18.9 Pneumonia, unspecified organism
- Patient account
- PA-462501
- Frequency code
- 1 (original)
- Accident
- Yes
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-040577 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-26 is after coverage terminated on 2026-06-05. Expenses incurred after coverage terminated |
| 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 (2514292657). | |
| 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 Hospital2026-06-26 13:14
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-04 03:49
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-08-04 17:20
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-462501.pdf8 pages
Itemised statement totalling $836.00 across 2 lines.
- Er reported_report_PA-462501.pdf4 pages
Emergency department record: triage acuity 3, chief complaint unspecified abdominal pain.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-06-26 is after coverage terminated on 2026-06-05.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.