CLM-2026-014341
Sunrise Community Hospital, Emergency Medicine. Service 2026-02-18 at emergency room (POS 23). Received 2026-02-23.
Member
Resolved through the identity graph
- Member
- James Gardner
- Member ID
- UHC-18662-01
- Date of birth
- 1993-12-01
- Identity
- Verified2 records, confidence 0.93
- Claim record
- CLMCLM-426942
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-4652
- Coverage period
- 2025-02-01 to present
- Deductible
- $45.06 of $1,000.005%
- Out-of-pocket maximum
- $503.94 of $2,000.0025%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 2411187117
- Network
- Out of network
- Rendering NPI
- 2411187117
- Location
- Tempe, AZ · TIN 19-3902018
- 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 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $2,714.00 | $1,221.30 | $350.00 | $871.30 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $153.00 | $68.85 | $0.00 | $68.85 | Paid |
| 3 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 2 | $638.00 | $287.10 | $0.00 | $287.10 | Paid |
| Totals | $3,505.00 | $1,577.25 | $350.00 | $1,227.25 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. R07.9 Chest pain, unspecified
- 3. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- Patient account
- PA-183620
- Frequency code
- 1 (original)
- Accident
- No
- 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-015378 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-02-18: MEDICARE-ADV-B (MA), effective 2025-02-01. | |
| Timely filing | Pass | Received 5 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Hospital2026-02-18 18:26
Established patient presents with pneumonia, unspecified organism; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-183620.pdf2 pages
Itemised statement totalling $3505.00 across 3 lines.
- Er reported_report_PA-183620.pdf6 pages
Emergency department record: triage acuity 3, 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 engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
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.