CLM-2026-021573
Sunrise Community Hospital, Emergency Medicine. Service 2026-04-23 at emergency room (POS 23). Received 2026-05-30.
Member
Resolved through the identity graph
- Member
- Nathan Santiago
- Member ID
- UHC-27681-55
- Date of birth
- 1943-12-11
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-429012
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-1283
- Coverage period
- 2023-11-01 to 2026-04-11
- Deductible
- $1,694.97 of $2,500.0068%
- Out-of-pocket maximum
- $647.11 of $5,000.0013%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 2310065109
- Network
- In network
- Rendering NPI
- 2310065109
- Location
- Mesa, AZ · TIN 51-3085459
- 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 | $158.00 | $86.90 | — | — | DeniedCO27 |
| Totals | $158.00 | $86.90 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. R55 Syncope and collapse
- Patient account
- PA-193156
- 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-004203 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-23 is after coverage terminated on 2026-04-11. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 37 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 Sunrise Community Hospital (2310065109). | |
| 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: Sunrise Community Hospital2026-04-23 11:45
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-05-30 01:09
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-05-30 16:15
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-193156.pdf6 pages
Itemised statement totalling $158.00 across 1 line.
- Er reported_report_PA-193156.pdf4 pages
Emergency department record: triage acuity 3, chief complaint chest pain, unspecified.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-04-23 is after coverage terminated on 2026-04-11.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.