CLM-2026-027690
Unity Community Hospital, Emergency Medicine. Service 2026-06-27 at emergency room (POS 23). Received 2026-07-12.
Member
Resolved through the identity graph
- Member
- Sara Hawkins
- Member ID
- UHC-71970-99
- Date of birth
- 1950-12-16
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-429365
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4631
- Coverage period
- 2021-04-01 to present
- Deductible
- $3,014.05 of $3,500.0086%
- Out-of-pocket maximum
- $3,871.83 of $10,500.0037%
- Copays
- office $30.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 14 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 | $1,092.00 | $600.60 | $350.00 | $250.60 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $179.00 | $98.45 | $0.00 | $98.45 | Paid |
| 3 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $3,049.00 | $1,676.95 | $0.00 | $1,676.95 | Paid |
| Totals | $4,320.00 | $2,376.00 | $350.00 | $2,026.00 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. J18.9 Pneumonia, unspecified organism
- 3. R55 Syncope and collapse
- Patient account
- PA-479580
- 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-036919 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-27: SELECT-EPO (EPO), effective 2021-04-01. | |
| Timely filing | Pass | Received 15 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 Hospital2026-06-27 09:23
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-479580.pdf9 pages
Itemised statement totalling $4320.00 across 3 lines.
- Er reported_report_PA-479580.pdf3 pages
Emergency department record: triage acuity 2, chief complaint chest pain, unspecified.
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-2026-027048 | 2026-07-09 | Meadow Primary Care Associates | $176.00 | Approved |
| CLM-2026-024766 | 2026-06-14 | Meadow Heart Institute | $318.00 | 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.