CLM-2026-018718
Unity Community Hospital, Emergency Medicine. Service 2026-02-20 at emergency room (POS 23). Received 2026-02-24.
Member
Resolved through the identity graph
- Member
- Daniel Allen
- Member ID
- UHC-80230-70
- Date of birth
- 1944-11-27
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-404509
- Relationship
- Spouse, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7126
- Coverage period
- 2021-08-01 to present
- Deductible
- $1,209.12 of $1,500.0081%
- Out-of-pocket maximum
- $2,061.84 of $6,000.0034%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 2 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 / REF776042
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 | $1,033.00 | $568.15 | $150.00 | $418.15 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $234.00 | $128.70 | $0.00 | $128.70 | Paid |
| Totals | $1,267.00 | $696.85 | $150.00 | $546.85 | ||||||
- 1. R55 Syncope and collapseprincipal
- Patient account
- PA-889572
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-010420 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-20: NAVIGATE-HMO (HMO), effective 2021-08-01. | |
| Timely filing | Pass | Received 4 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 Hospital2026-02-20 14:42
Follow-up for syncope and collapse. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-889572.pdf5 pages
Itemised statement totalling $1267.00 across 2 lines.
- Er reported_report_PA-889572.pdf6 pages
Emergency department record: triage acuity 4, 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 engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002638 | 2026-08-22 | Northgate Clinical Laboratories | $104.00 | Approved |
| CLM-2026-029591 | 2026-02-16 | Riverside Regional Medical Center | $1,943.00 | Needs review |
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.