CLM-2026-022663
Canyon Community Hospital, Emergency Medicine. Service 2026-05-13 at emergency room (POS 23). Received 2026-06-23.
Member
Resolved through the identity graph
- Member
- Debra Stone
- Member ID
- UHC-48866-06
- Date of birth
- 1962-03-19
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-432462
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3380
- Coverage period
- 2023-04-01 to present
- Deductible
- $213.11 of $500.0043%
- Out-of-pocket maximum
- $294.08 of $1,500.0020%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 6 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 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,271.00 | $571.95 | $150.00 | $421.95 | Paid |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $813.00 | $365.85 | $0.00 | $365.85 | Paid |
| Totals | $2,084.00 | $937.80 | $150.00 | $787.80 | ||||||
- 1. R55 Syncope and collapseprincipal
- 2. R10.9 Unspecified abdominal pain
- 3. J18.9 Pneumonia, unspecified organism
- Patient account
- PA-991739
- 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-036021 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-13: N/A (PPO), effective 2023-04-01. | |
| Timely filing | Pass | Received 41 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 Hospital2026-05-13 13:34
Follow-up for syncope and collapse. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-991739.pdf8 pages
Itemised statement totalling $2084.00 across 2 lines.
- Er reported_report_PA-991739.pdf5 pages
Emergency department record: triage acuity 2, chief complaint syncope and collapse.
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.