CLM-2026-027545
Unity Community Hospital, Emergency Medicine. Service 2026-02-07 at emergency room (POS 23). Received 2026-03-09.
Member
Resolved through the identity graph
- Member
- Lori Duncan
- Member ID
- UHC-77386-40
- Date of birth
- 1965-10-18
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-403501
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-2895
- Coverage period
- 2025-04-01 to present
- Deductible
- $1,347.53 of $2,500.0054%
- Out-of-pocket maximum
- $2,080.24 of $5,000.0042%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 20 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 / REF662864
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 | $961.00 | $528.55 | — | — | Review |
| Totals | $961.00 | $528.55 | — | — | ||||||
- 1. S93.401A Sprain of unspecified ligament of right ankle, initial encounterprincipal
- Patient account
- PA-229458
- 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-018601 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-07: NAVIGATE-HMO (HMO), effective 2025-04-01. | |
| Timely filing | Pass | Received 30 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 | Review | CO16 | Documentation incomplete: “Follow-up for sprain of unspecified ligament of right ankle, initial encounter. Plan discu”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Unity Community Hospital2026-02-07 18:30
Follow-up for sprain of unspecified ligament of right ankle, initial encounter. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-03-09 00:24
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-03-09 13:56
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-229458.pdf8 pages
Itemised statement totalling $961.00 across 1 line.
- Er reported_report_PA-229458.pdf4 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 engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Follow-up for sprain of unspecified ligament of right ankle, initial encounter. Plan discu”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029993 | 2026-10-01 | Desert Internal Medicine Associates | $377.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.