CLM-2026-028093
Canyon Community Hospital, Emergency Medicine. Service 2026-05-01 at emergency room (POS 23). Received 2026-05-07.
Member
Resolved through the identity graph
- Member
- Wayne Jimenez
- Member ID
- UHC-99311-81
- Date of birth
- 1947-09-19
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-412456
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7524
- Coverage period
- 2023-03-01 to present
- Deductible
- $308.96 of $2,500.0012%
- Out-of-pocket maximum
- $647.86 of $7,500.009%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 9109847134
- Network
- Out of network
- Rendering NPI
- 9109847134
- Location
- Phoenix, AZ · TIN 21-6618841
- 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 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $2,553.00 | $1,148.85 | $350.00 | $798.85 | Paid |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $695.00 | $312.75 | $0.00 | $312.75 | Paid |
| 3 | 71046 rev 0320 | Chest X-ray, two views | 25 | 1 | 2 | $225.00 | $101.25 | $0.00 | $101.25 | Paid |
| Totals | $3,473.00 | $1,562.85 | $350.00 | $1,212.85 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-363035
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-014084 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-05-01: CHOICE-PLUS-PPO (PPO), effective 2023-03-01. | |
| Timely filing | Pass | Received 6 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Canyon Community Hospital2026-05-01 18:25
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-363035.pdf2 pages
Itemised statement totalling $3473.00 across 3 lines.
- Er reported_report_PA-363035.pdf3 pages
Emergency department record: triage acuity 3, 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 engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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.