CLM-2026-021141
Unity Community Hospital, Emergency Medicine. Service 2026-08-20 at emergency room (POS 23). Received 2026-09-07.
Member
Resolved through the identity graph
- Member
- Ahmed Hernandez
- Member ID
- UHC-21736-01
- Date of birth
- 1942-04-15
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-415424
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4600
- Coverage period
- 2025-01-01 to present
- Deductible
- $808.76 of $1,000.0081%
- Out-of-pocket maximum
- $480.79 of $4,000.0012%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- 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 / 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 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $146.00 | $80.30 | $80.30 | $0.00 | Paid |
| Totals | $146.00 | $80.30 | $80.30 | $0.00 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. J18.9 Pneumonia, unspecified organism
- Patient account
- PA-160198
- Frequency code
- 1 (original)
- Accident
- No
- 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-003163 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-20: SELECT-EPO (EPO), effective 2025-01-01. | |
| Timely filing | Pass | Received 18 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 Hospital2026-08-20 18:18
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-160198.pdf2 pages
Itemised statement totalling $146.00 across 1 line.
- Er reported_report_PA-160198.pdf4 pages
Emergency department record: triage acuity 3, chief complaint chest pain, unspecified.
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-2026-001054 | 2026-03-01 | Evergreen Primary Care Associates | $316.00 | Approved |
| CLM-2026-005327 | 2026-01-02 | Harbor Clinical Laboratories | $158.00 | Denied |
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.