CLM-2026-016133
Unity Community Hospital, Emergency Medicine. Service 2026-09-05 at emergency room (POS 23). Received 2026-10-12.
Member
Resolved through the identity graph
- Member
- Richard Clark
- Member ID
- UHC-54936-57
- Date of birth
- 1972-10-03
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-431477
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8367
- Coverage period
- 2021-12-01 to present
- Deductible
- $241.68 of $500.0048%
- Out-of-pocket maximum
- $336.34 of $1,000.0034%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 19 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 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $2,496.00 | $1,372.80 | — | — | DeniedCO18 |
| Totals | $2,496.00 | $1,372.80 | — | — | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- Patient account
- PA-715942
- 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-003770 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-05: CHOICE-PLUS-PPO (PPO), effective 2021-12-01. | |
| Timely filing | Pass | Received 37 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-016132: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| 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 Hospital2026-09-05 15:10
Established patient presents with pneumonia, unspecified organism; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-10-12 04:52
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
- Itemized billitemized_PA-715942.pdf6 pages
Itemised statement totalling $2496.00 across 1 line.
- Er reported_report_PA-715942.pdf3 pages
Emergency department record: triage acuity 4, chief complaint pneumonia, unspecified organism.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-016132: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016132 | 2026-09-05 | Unity Community Hospital | $2,496.00 | Approved |
| CLM-2026-009783 | 2025-12-14 | Lakeside Dermatology Clinic | $285.00 | Approved |
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
Exact duplicate of an earlier submission.