CLM-2026-026107
Sunrise Community Hospital, Emergency Medicine. Service 2026-04-14 at emergency room (POS 23). Received 2026-05-06.
Member
Resolved through the identity graph
- Member
- Cheryl Collins
- Member ID
- UHC-48515-83
- Date of birth
- 1992-04-14
- Identity
- Verified3 records, confidence 0.94
- Claim record
- CLMCLM-410472
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4207
- Coverage period
- 2024-09-01 to 2026-04-04
- Deductible
- $46.53 of $1,500.003%
- Out-of-pocket maximum
- $2,125.68 of $4,500.0047%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 17 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 | $993.00 | $546.15 | — | — | DeniedCO27 |
| 2 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $2,144.00 | $1,179.20 | — | — | DeniedCO27 |
| Totals | $3,137.00 | $1,725.35 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-633057
- Frequency code
- 1 (original)
- Accident
- No
- 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-008189 (verified, link confidence 0.94). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-14 is after coverage terminated on 2026-04-04. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 22 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 Hospital2026-04-14 09:47
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-05-06 06:17
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-05-06 09:20
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-633057.pdf2 pages
Itemised statement totalling $3137.00 across 2 lines.
- Er reported_report_PA-633057.pdf6 pages
Emergency department record: triage acuity 3, chief complaint unspecified abdominal pain.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-04-14 is after coverage terminated on 2026-04-04.
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.