CLM-2026-016407
Sunrise Community Hospital, Emergency Medicine. Service 2026-07-07 at emergency room (POS 23). Received 2026-07-21.
Member
Resolved through the identity graph
- Member
- Ethan Walsh
- Member ID
- none on golden record
- Date of birth
- 1941-03-07
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-412683
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Eligibility
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 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $1,014.00 | $456.30 | — | — | PendedN30 |
| 2 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1,2 | $1,828.00 | $822.60 | — | — | PendedN30 |
| Totals | $2,842.00 | $1,278.90 | — | — | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-924188
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-039208 (verified, link confidence 0.97). | |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 14 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 Hospital2026-07-07 10:48
Patient seen for pneumonia, unspecified organism.
Attachments
Documents received with the claim
- Itemized billitemized_PA-924188.pdf2 pages
Itemised statement totalling $2842.00 across 2 lines.
- Er reported_report_PA-924188.pdf4 pages
Emergency department record: triage acuity 2, chief complaint pneumonia, unspecified organism.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Eligibility: No coverage segment found for the member ID on this claim. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016408 | 2026-07-07 | Unity Community Hospital | $2,842.00 | Pended |
| CLM-2026-025951 | 2026-07-04 | Meadow Clinical Laboratories | $83.00 | Pended |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.