CLM-2026-025479
Sunrise Community Hospital, Emergency Medicine. Service 2026-04-18 at emergency room (POS 23). Received 2026-04-21.
Member
Resolved through the identity graph
- Member
- Carlos Le
- Member ID
- UHC-07359-80
- Date of birth
- 1944-10-15
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-413621
- Relationship
- Child, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-7849
- Coverage period
- 2025-07-01 to present
- Deductible
- $110.01 of $500.0022%
- Out-of-pocket maximum
- $987.32 of $2,000.0049%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 2310065109
- Network
- In network
- Rendering NPI
- 2310065109
- Location
- Mesa, AZ · TIN 51-3085459
- 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 | $1,008.00 | $554.40 | $250.00 | $304.40 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | 25 | 1 | 1 | $212.00 | $116.60 | $0.00 | $116.60 | Paid |
| Totals | $1,220.00 | $671.00 | $250.00 | $421.00 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-196057
- 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-027058 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-18: OPTIONS-PPO (PPO), effective 2025-07-01. | |
| Timely filing | Pass | Received 3 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 Sunrise Community Hospital (2310065109). | |
| 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 10:00
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-196057.pdf4 pages
Itemised statement totalling $1220.00 across 2 lines.
- Er reported_report_PA-196057.pdf5 pages
Emergency department record: triage acuity 2, chief complaint unspecified abdominal pain.
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
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.