CLM-2026-022102
Unity Community Hospital, Emergency Medicine. Service 2026-04-17 at emergency room (POS 23). Received 2026-05-17.
Member
Resolved through the identity graph
- Member
- Kelly Mason
- Member ID
- UHC-40432-40
- Date of birth
- 1950-04-08
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-426684
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group -
- Coverage period
- 2025-04-01 to 2026-03-20
- Deductible
- $59.73 of $500.0012%
- Out-of-pocket maximum
- $354.44 of $1,000.0035%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 20 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 | $231.00 | $127.05 | — | — | DeniedCO27 |
| 2 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $3,076.00 | $1,691.80 | — | — | DeniedCO27 |
| Totals | $3,307.00 | $1,818.85 | — | — | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- Patient account
- PA-231304
- Frequency code
- 1 (original)
- Accident
- Yes
- 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-023247 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-17 is after coverage terminated on 2026-03-20. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 30 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 Hospital2026-04-17 17:17
Follow-up for pneumonia, unspecified organism. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-05-17 02:26
Attachments
Documents received with the claim
- Itemized billitemized_PA-231304.pdf6 pages
Itemised statement totalling $3307.00 across 2 lines.
- Er reported_report_PA-231304.pdf5 pages
Emergency department record: triage acuity 2, chief complaint pneumonia, unspecified organism.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-04-17 is after coverage terminated on 2026-03-20.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-006835 | 2026-07-24 | Riverside Clinical Laboratories | $80.00 | Denied |
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.