CLM-2026-018012
Unity Community Hospital, Emergency Medicine. Service 2026-08-22 at emergency room (POS 23). Received 2026-10-05.
Member
Resolved through the identity graph
- Member
- Sandra Dominguez
- Member ID
- UHC-22951-96
- Date of birth
- 1971-11-14
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-410884
- Relationship
- Spouse
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-8391
- Coverage period
- 2021-02-01 to present
- Deductible
- $238.93 of $1,000.0024%
- Out-of-pocket maximum
- $749.57 of $2,000.0037%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 15 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 / 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 | $2,591.00 | $1,425.05 | — | — | PendedIDQ |
| Totals | $2,591.00 | $1,425.05 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. R10.9 Unspecified abdominal pain
- 3. J18.9 Pneumonia, unspecified organism
- Patient account
- PA-848940
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-001365; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-08-22: MEDICARE-ADV-A (MA), effective 2021-02-01. | |
| Timely filing | Pass | Received 44 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 Hospital2026-08-22 17:18
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-848940.pdf8 pages
Itemised statement totalling $2591.00 across 1 line.
- Er reported_report_PA-848940.pdf5 pages
Emergency department record: triage acuity 2, chief complaint chest pain, unspecified.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-001365; payment withheld until the identity is confirmed.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.