CLM-2026-024579
Sunrise Community Hospital, Emergency Medicine. Service 2026-04-18 at emergency room (POS 23). Received 2026-05-19.
Member
Resolved through the identity graph
- Member
- Amy Hudson
- Member ID
- UHC-71705-45
- Date of birth
- 1939-09-27
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-416604
- Relationship
- Spouse, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-8775
- Coverage period
- 2024-05-01 to 2026-02-04
- Deductible
- $2,556.67 of $3,500.0073%
- Out-of-pocket maximum
- $1,786.54 of $7,000.0026%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 9 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 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $714.00 | $321.30 | — | — | DeniedCO27 |
| Totals | $714.00 | $321.30 | — | — | ||||||
- 1. S93.401A Sprain of unspecified ligament of right ankle, initial encounterprincipal
- Patient account
- PA-199064
- Frequency code
- 1 (original)
- Accident
- Yes
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-031332 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-18 is after coverage terminated on 2026-02-04. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 31 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 Hospital2026-04-18 13:54
Patient seen for sprain of unspecified ligament of right ankle, initial encounter.
- SystemSystem: Claims system2026-05-19 05:09
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-05-19 15:32
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-199064.pdf2 pages
Itemised statement totalling $714.00 across 1 line.
- Er reported_report_PA-199064.pdf2 pages
Emergency department record: triage acuity 2, chief complaint sprain of unspecified ligament of right ankle, initial encounter.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-04-18 is after coverage terminated on 2026-02-04. Provider 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
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.