CLM-2026-016711
Summit Regional Medical Center, Emergency Medicine. Service 2026-01-31 at emergency room (POS 23). Received 2026-05-15.
Member
Resolved through the identity graph
- Member
- Jose Carpenter
- Member ID
- UHC-84499-49
- Date of birth
- 1943-04-07
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-432027
- Relationship
- Spouse, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-0512
- Coverage period
- 2023-12-01 to present
- Deductible
- $27.93 of $1,500.002%
- Out-of-pocket maximum
- $900.38 of $3,000.0030%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 7959926214
- Network
- In network
- Rendering NPI
- 7959926214
- Location
- Mesa, AZ · TIN 13-8570749
- 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 | $2,663.00 | $1,464.65 | — | — | DeniedCO29 |
| Totals | $2,663.00 | $1,464.65 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- Patient account
- PA-232631
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-012654 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-31: MEDICARE-ADV-B (MA), effective 2023-12-01. | |
| Timely filing | Fail | CO29 | Received 104 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Summit Regional Medical Center (7959926214). | |
| 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: Summit Regional Medical Center2026-01-31 17:58
Patient seen for unspecified abdominal pain.
- SystemSystem: Claims system2026-05-15 05:55
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
- Itemized billitemized_PA-232631.pdf4 pages
Itemised statement totalling $2663.00 across 1 line.
- Er reported_report_PA-232631.pdf5 pages
Emergency department record: triage acuity 4, chief complaint unspecified abdominal pain.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 104 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004200 | 2026-08-18 | Lakeside Medical Group | $40.00 | Approved |
| CLM-2026-029895 | 2026-05-24 | Pinecrest Internal Medicine Associates | $312.00 | 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
Received after the timely-filing limit.