CLM-2026-022496
Canyon Community Hospital, Emergency Medicine. Service 2026-07-11 at emergency room (POS 23). Received 2026-08-07.
Member
Resolved through the identity graph
- Member
- Zachary Evans
- Member ID
- UHC-63508-30
- Date of birth
- 1988-09-27
- Identity
- Verified3 records, confidence 0.93
- Claim record
- CLMCLM-419545
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-7811
- Coverage period
- 2025-01-01 to present
- Deductible
- $1,205.75 of $1,500.0080%
- Out-of-pocket maximum
- $410.71 of $6,000.007%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 9109847134
- Network
- Out of network
- Rendering NPI
- 9109847134
- Location
- Phoenix, AZ · TIN 21-6618841
- 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 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $643.00 | $289.35 | $150.00 | $139.35 | Paid |
| 2 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,457.00 | $655.65 | $0.00 | $655.65 | Paid |
| 3 | 96374 rev 0260 | IV push, single drug | — | 1 | 1,2 | $166.00 | $74.70 | $0.00 | $74.70 | Paid |
| Totals | $2,266.00 | $1,019.70 | $150.00 | $869.70 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. R55 Syncope and collapse
- Patient account
- PA-541704
- 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-001637 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-07-11: NULL (PPO), effective 2025-01-01. | |
| Timely filing | Pass | Received 27 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Canyon Community Hospital2026-07-11 09:29
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-541704.pdf3 pages
Itemised statement totalling $2266.00 across 3 lines.
- Er reported_report_PA-541704.pdf5 pages
Emergency department record: triage acuity 4, 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 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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.