CLM-2026-015903
Sunrise Community Hospital, Emergency Medicine. Service 2026-02-24 at emergency room (POS 23). Received 2026-03-21.
Member
Resolved through the identity graph
- Member
- Paul Bailey
- Member ID
- UHC-74026-83
- Date of birth
- 1947-01-06
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-410602
- Relationship
- Spouse, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-5576
- Coverage period
- 2024-07-01 to present
- Deductible
- $309.10 of $1,000.0031%
- Out-of-pocket maximum
- $1,889.89 of $4,000.0047%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 3 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 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $2,174.00 | $1,195.70 | $150.00 | $1,045.70 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $121.00 | $66.55 | $0.00 | $66.55 | Paid |
| 3 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $254.00 | $139.70 | $0.00 | $139.70 | Paid |
| Totals | $2,549.00 | $1,401.95 | $150.00 | $1,251.95 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- Patient account
- PA-331509
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-010242 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-24: OPTIONS-PPO (PPO), effective 2024-07-01. | |
| Timely filing | Pass | Received 25 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 14:06
Patient seen for pneumonia, unspecified organism.
Attachments
Documents received with the claim
- Itemized billitemized_PA-331509.pdf9 pages
Itemised statement totalling $2549.00 across 3 lines.
- Er reported_report_PA-331509.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 engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031477 | 2026-07-08 | Mesa Primary Care Associates | $3,180.00 | Needs review |
| CLM-2026-012458 | 2026-02-01 | Sunrise Medical Group | $250.00 | Approved |
| CLM-2026-018794 | 2026-01-24 | Canyon Regional Medical Center | $1,021.00 | Needs review |
| CLM-2026-018793 | 2026-01-24 | Unity Community Hospital | $1,021.00 | 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.