CLM-2026-022509
Sunrise Community Hospital, Emergency Medicine. Service 2026-05-10 at emergency room (POS 23). Received 2026-05-21.
Member
Resolved through the identity graph
- Member
- Steven Cole
- Member ID
- UHC-97690-65
- Date of birth
- 1982-09-07
- Identity
- Verified5 records, confidence 0.94
- Claim record
- CLMCLM-428102
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7243
- Coverage period
- 2022-06-01 to present
- Deductible
- $471.73 of $1,000.0047%
- Out-of-pocket maximum
- $36.69 of $3,000.001%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 2411187117
- Network
- Out of network
- Rendering NPI
- 2411187117
- Location
- Tempe, AZ · TIN 19-3902018
- 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 | $176.00 | $79.20 | $79.20 | $0.00 | Paid |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $752.00 | $338.40 | $0.00 | $338.40 | Paid |
| Totals | $928.00 | $417.60 | $79.20 | $338.40 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-552959
- Frequency code
- 1 (original)
- Accident
- Yes
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-006513 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2026-05-10: CHOICE-PLUS-PPO (PPO), effective 2022-06-01. | |
| Timely filing | Pass | Received 11 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: Sunrise Community Hospital2026-05-10 14:21
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-552959.pdf4 pages
Itemised statement totalling $928.00 across 2 lines.
- Er reported_report_PA-552959.pdf6 pages
Emergency department record: triage acuity 3, 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 engineApproved2026-10-21 13:43Provider 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.