CLM-2026-019106
Summit Regional Medical Center, Emergency Medicine. Service 2026-05-12 at emergency room (POS 23). Received 2026-07-02.
Member
Resolved through the identity graph
- Member
- Dennis Elliott
- Member ID
- UHC-36167-23
- Date of birth
- 1944-08-12
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-425010
- Relationship
- Spouse, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3623
- Coverage period
- 2021-07-01 to present
- Deductible
- $225.50 of $500.0045%
- Out-of-pocket maximum
- $157.21 of $2,000.008%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 7959926214
- Network
- In network
- Rendering NPI
- 2102151364 (Heritage Community Hospital)
- Location
- Mesa, AZ · TIN 13-8570749
- 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 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $1,070.00 | $588.50 | — | — | Review |
| 2 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | 25 | 1 | 1 | $1,614.00 | $887.70 | — | — | Review |
| 3 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 2 | $1,419.00 | $780.45 | — | — | Review |
| Totals | $4,103.00 | $2,256.65 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-674182
- Frequency code
- 1 (original)
- Accident
- No
- 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-002061 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-12: OPTIONS-PPO (PPO), effective 2021-07-01. | |
| Timely filing | Pass | Received 51 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-019105, billed by a different provider. Possible duplicate |
| 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 Center2026-05-12 13:42
Patient seen for unspecified abdominal pain. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-07-02 01:31
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-07-02 17:02
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-674182.pdf2 pages
Itemised statement totalling $4103.00 across 3 lines.
- Er reported_report_PA-674182.pdf3 pages
Emergency department record: triage acuity 4, chief complaint unspecified abdominal pain.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Duplicate check: Same member, date of service and procedures as CLM-2026-019105, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019105 | 2026-05-12 | Heritage Community Hospital | $4,103.00 | Approved |
| CLM-2026-013757 | 2025-12-17 | Heritage GI Associates | $1,722.00 | Approved |
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
Different billing provider; separately payable.