CLM-2026-024911
Unity Community Hospital, Emergency Medicine. Service 2026-07-15 at emergency room (POS 23). Received 2026-08-08.
Member
Resolved through the identity graph
- Member
- Zachary Mendez
- Member ID
- UHC-28618-02
- Date of birth
- 2003-01-26
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-432827
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-9241
- Coverage period
- 2024-11-01 to present
- Deductible
- $2,956.29 of $3,500.0084%
- Out-of-pocket maximum
- $4,784.33 of $10,500.0046%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 5583357806
- Network
- In network
- Rendering NPI
- 5583357806
- Location
- Tempe, AZ · TIN 68-0325602
- 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 | $1,331.00 | $732.05 | $150.00 | $582.05 | Paid |
| Totals | $1,331.00 | $732.05 | $150.00 | $582.05 | ||||||
- 1. R55 Syncope and collapseprincipal
- 2. R07.9 Chest pain, unspecified
- 3. J18.9 Pneumonia, unspecified organism
- Patient account
- PA-614321
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-009380 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-07-15: MEDICARE-ADV-A (MA), effective 2024-11-01. | |
| Timely filing | Pass | Received 24 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 | Pass | In-network provider Unity Community Hospital (5583357806). | |
| 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: Unity Community Hospital2026-07-15 13:46
Patient seen for syncope and collapse.
Attachments
Documents received with the claim
- Itemized billitemized_PA-614321.pdf8 pages
Itemised statement totalling $1331.00 across 1 line.
- Er reported_report_PA-614321.pdf2 pages
Emergency department record: triage acuity 3, 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 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012089 | 2026-05-20 | Summit Heart Institute | $467.00 | Denied |
| CLM-2026-016444 | 2026-05-19 | Evergreen GI Associates | $4,644.00 | Needs review |
| CLM-2026-012088 | 2026-05-20 | Summit Heart Institute | $467.00 | Approved |
| CLM-2026-016443 | 2026-05-19 | Riverside Digestive Health Center | $4,644.00 | Approved |
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.