CLM-2026-016988
Sunrise Community Hospital, Emergency Medicine. Service 2025-12-13 at emergency room (POS 23). Received 2026-01-07.
Member
Resolved through the identity graph
- Member
- Christian Kennedy
- Member ID
- UHC-25677-82
- Date of birth
- 1938-09-22
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-414271
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-2064
- Coverage period
- 2021-05-01 to present
- Deductible
- $14.38 of $1,500.001%
- Out-of-pocket maximum
- $2,444.44 of $6,000.0041%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 11 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 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,181.00 | $531.45 | $150.00 | $381.45 | Paid |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $795.00 | $357.75 | $0.00 | $357.75 | Paid |
| 3 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $247.00 | $111.15 | $0.00 | $111.15 | Paid |
| Totals | $2,223.00 | $1,000.35 | $150.00 | $850.35 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. R55 Syncope and collapse
- 3. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- Patient account
- PA-474263
- 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-002067 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-13: MEDICARE-ADV-A (MA), effective 2021-05-01. | |
| 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 | 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 Hospital2025-12-13 17:19
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-474263.pdf8 pages
Itemised statement totalling $2223.00 across 3 lines.
- Er reported_report_PA-474263.pdf6 pages
Emergency department record: triage acuity 3, chief complaint chest pain, unspecified.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider 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.