CLM-2026-021434
Summit Regional Medical Center, Emergency Medicine. Service 2026-06-30 at emergency room (POS 23). Received 2026-08-07.
Member
Resolved through the identity graph
- Member
- Evelyn Delgado
- Member ID
- UHC-46372-43
- Date of birth
- 1961-10-05
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-420038
- Relationship
- Spouse, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-4662
- Coverage period
- 2022-01-01 to present
- Deductible
- $1,685.84 of $2,500.0067%
- Out-of-pocket maximum
- $2,476.01 of $7,500.0033%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 20 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 / 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 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $2,094.00 | $1,151.70 | $250.00 | $901.70 | Paid |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $828.00 | $455.40 | $0.00 | $455.40 | Paid |
| 3 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,254.00 | $689.70 | $0.00 | $689.70 | Paid |
| Totals | $4,176.00 | $2,296.80 | $250.00 | $2,046.80 | ||||||
- 1. R55 Syncope and collapseprincipal
- Patient account
- PA-775758
- 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-010217 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-30: CORE-HMO (HMO), effective 2022-01-01. | |
| Timely filing | Pass | Received 38 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 Center2026-06-30 11:04
Patient seen for syncope and collapse.
Attachments
Documents received with the claim
- Itemized billitemized_PA-775758.pdf3 pages
Itemised statement totalling $4176.00 across 3 lines.
- Er reported_report_PA-775758.pdf3 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
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.