CLM-2026-018598
Sunrise Community Hospital, Emergency Medicine. Service 2026-02-17 at emergency room (POS 23). Received 2026-03-31.
Member
Resolved through the identity graph
- Member
- Debra Mendez
- Member ID
- UHC-40056-84
- Date of birth
- 1960-06-24
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-424653
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-0158
- Coverage period
- 2021-09-01 to present
- Deductible
- $1,724.44 of $3,500.0049%
- Out-of-pocket maximum
- $2,206.49 of $7,000.0032%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 2310065109
- Network
- In network
- Rendering NPI
- 2310065109
- Location
- Mesa, AZ · TIN 51-3085459
- 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 | $1,247.00 | $685.85 | $350.00 | $335.85 | Paid |
| Totals | $1,247.00 | $685.85 | $350.00 | $335.85 | ||||||
- 1. R55 Syncope and collapseprincipal
- 2. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- Patient account
- PA-303001
- 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-023191 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-17: MEDICARE-ADV-B (MA), effective 2021-09-01. | |
| Timely filing | Pass | Received 42 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 Sunrise Community Hospital (2310065109). | |
| 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 Hospital2026-02-17 18:28
Follow-up for syncope and collapse. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-303001.pdf2 pages
Itemised statement totalling $1247.00 across 1 line.
- Er reported_report_PA-303001.pdf5 pages
Emergency department record: triage acuity 2, 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022082 | 2026-06-05 | Mesa Family Practice | $435.00 | Approved |
| CLM-2026-018599 | 2026-02-17 | Sunrise Community Hospital | $1,247.00 | Needs review |
| CLM-2026-019568 | 2026-03-29 | Canyon Cardiovascular Associates | $1,456.00 | 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.