CLM-2026-019779
Summit Regional Medical Center, Emergency Medicine. Service 2026-02-14 at emergency room (POS 23). Received 2026-03-09.
Member
Resolved through the identity graph
- Member
- Sofai Dominguez
- Member ID
- UHC-86327-43
- Date of birth
- 1951-12-27
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-401065
- Relationship
- Spouse, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-5338
- Coverage period
- 2023-05-01 to present
- Deductible
- $205.04 of $500.0041%
- Out-of-pocket maximum
- $619.44 of $2,000.0031%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 1269847210
- Network
- In network
- Rendering NPI
- 1269847210
- Location
- Mesa, AZ · TIN 62-8021640
- Authorisation / referral
- none / REF443580
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 | $1,799.00 | $989.45 | $150.00 | $839.45 | Paid |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $926.00 | $509.30 | $0.00 | $509.30 | Paid |
| 3 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $217.00 | $119.35 | $0.00 | $119.35 | Paid |
| Totals | $2,942.00 | $1,618.10 | $150.00 | $1,468.10 | ||||||
- 1. S93.401A Sprain of unspecified ligament of right ankle, initial encounterprincipal
- Patient account
- PA-180314
- 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-018535 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-14: CORE-HMO (HMO), effective 2023-05-01. | |
| Timely filing | Pass | Received 23 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 (1269847210). | |
| 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 Center2026-02-14 16:13
Established patient presents with sprain of unspecified ligament of right ankle, initial encounter; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-180314.pdf8 pages
Itemised statement totalling $2942.00 across 3 lines.
- Er reported_report_PA-180314.pdf5 pages
Emergency department record: triage acuity 3, chief complaint sprain of unspecified ligament of right ankle, initial encounter.
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
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.