CLM-2026-017259
Unity Community Hospital, Emergency Medicine. Service 2025-12-29 at emergency room (POS 23). Received 2026-02-01.
Member
Resolved through the identity graph
- Member
- Tyler Barnes
- Member ID
- UHC-01576-41
- Date of birth
- 1943-05-11
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-412699
- Relationship
- Spouse, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-9475
- Coverage period
- 2025-12-01 to present
- Deductible
- $2,077.82 of $2,500.0083%
- Out-of-pocket maximum
- $837.95 of $10,000.008%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 20 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 / REF671828
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 | $1,631.00 | $897.05 | $350.00 | $547.05 | Paid |
| 2 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $2,531.00 | $1,392.05 | $0.00 | $1,392.05 | Paid |
| Totals | $4,162.00 | $2,289.10 | $350.00 | $1,939.10 | ||||||
- 1. R55 Syncope and collapseprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-874608
- Frequency code
- 1 (original)
- Accident
- Yes
- 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-009338 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2025-12-29: NAVIGATE-HMO (HMO), effective 2025-12-01. | |
| Timely filing | Pass | Received 34 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 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 Hospital2025-12-29 12:23
Established patient presents with syncope and collapse; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-874608.pdf9 pages
Itemised statement totalling $4162.00 across 2 lines.
- Er reported_report_PA-874608.pdf5 pages
Emergency department record: triage acuity 3, chief complaint syncope and collapse.
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
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.