CLM-2026-017374
Summit Regional Medical Center, Emergency Medicine. Service 2026-06-10 at emergency room (POS 23). Received 2026-07-23.
Member
Resolved through the identity graph
- Member
- Anthony Fisher
- Member ID
- UHC-22188-38
- Date of birth
- 1938-01-15
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-409344
- Relationship
- Spouse, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group -
- Coverage period
- 2022-03-01 to 2026-05-16
- Deductible
- $1,895.07 of $3,500.0054%
- Out-of-pocket maximum
- $3,989.33 of $10,500.0038%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 6 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 / REF430856
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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $193.00 | $106.15 | — | — | DeniedCO27 |
| 2 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $166.00 | $91.30 | — | — | DeniedCO27 |
| Totals | $359.00 | $197.45 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-488453
- Frequency code
- 1 (original)
- Accident
- Yes
- 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-025623 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-10 is after coverage terminated on 2026-05-16. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 43 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 Center2026-06-10 14:15
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-23 00:13
Attachments
Documents received with the claim
- Itemized billitemized_PA-488453.pdf8 pages
Itemised statement totalling $359.00 across 2 lines.
- Er reported_report_PA-488453.pdf6 pages
Emergency department record: triage acuity 3, chief complaint chest pain, unspecified.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-06-10 is after coverage terminated on 2026-05-16.
Other claims for this member
Same resolved identity
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
Service after coverage termination.