CLM-2026-017204
Summit Regional Medical Center, Emergency Medicine. Service 2026-06-17 at emergency room (POS 23). Received 2026-07-17.
Member
Resolved through the identity graph
- Member
- Madison Rivera
- Member ID
- UHC-25876-36
- Date of birth
- 1984-04-07
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-411212
- Relationship
- Child, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4155
- Coverage period
- 2023-11-01 to present
- Deductible
- $2,386.79 of $3,500.0068%
- Out-of-pocket maximum
- $6,211.54 of $14,000.0044%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 0 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 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $898.00 | $493.90 | $350.00 | $143.90 | Paid |
| 2 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,351.00 | $743.05 | $0.00 | $743.05 | Paid |
| 3 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 2 | $1,828.00 | $1,005.40 | $0.00 | $1,005.40 | Paid |
| Totals | $4,077.00 | $2,242.35 | $350.00 | $1,892.35 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-159583
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-012440 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-17: SELECT-EPO (EPO), effective 2023-11-01. | |
| Timely filing | Pass | Received 30 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 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 Center2026-06-17 16:56
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-159583.pdf7 pages
Itemised statement totalling $4077.00 across 3 lines.
- Er reported_report_PA-159583.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 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-008752 | 2026-01-25 | Mesa Dermatology Clinic | $308.00 | 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.