CLM-2026-022219
Summit Regional Medical Center, Emergency Medicine. Service 2026-05-29 at emergency room (POS 23). Received 2026-06-05.
Member
Resolved through the identity graph
- Member
- Lauren Mills
- Member ID
- UHC-36346-77
- Date of birth
- 2000-08-18
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-416148
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8114
- Coverage period
- 2022-04-01 to present
- Deductible
- $352.51 of $500.0071%
- Out-of-pocket maximum
- $652.41 of $2,000.0033%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 1269847210
- Network
- In network
- Rendering NPI
- 7874072318 (Canyon Regional Medical Center)
- Location
- Mesa, AZ · TIN 62-8021640
- Authorisation / referral
- none / REF864702
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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $202.00 | $111.10 | — | — | Review |
| 2 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $232.00 | $127.60 | — | — | Review |
| Totals | $434.00 | $238.70 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-528630
- 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-033150 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-29: CORE-HMO (HMO), effective 2022-04-01. | |
| Timely filing | Pass | Received 7 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-022218, billed by a different provider. Possible duplicate |
| 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 Center2026-05-29 14:00
Patient seen for unspecified abdominal pain. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-06-05 06:29
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
Attachments
Documents received with the claim
- Itemized billitemized_PA-528630.pdf9 pages
Itemised statement totalling $434.00 across 2 lines.
- Er reported_report_PA-528630.pdf2 pages
Emergency department record: triage acuity 4, chief complaint unspecified abdominal pain.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Duplicate check: Same member, date of service and procedures as CLM-2026-022218, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022218 | 2026-05-29 | Canyon Regional Medical Center | $434.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Different billing provider; separately payable.