CLM-2026-028980
Summit Regional Medical Center, Emergency Medicine. Service 2026-08-08 at emergency room (POS 23). Received 2026-08-20.
Member
Resolved through the identity graph
- Member
- Alexander Perkins
- Member ID
- UHC-60662-97
- Date of birth
- 1959-03-26
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-416533
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7341
- Coverage period
- 2021-06-01 to 2026-02-14
- Deductible
- $26.53 of $500.005%
- Out-of-pocket maximum
- $644.82 of $1,500.0043%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 7959926214
- Network
- In network
- Rendering NPI
- 7959926214
- Location
- Mesa, AZ · TIN 13-8570749
- 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 | $1,051.00 | $578.05 | — | — | DeniedCO27 |
| 2 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 2 | $2,464.00 | $1,355.20 | — | — | DeniedCO27 |
| Totals | $3,515.00 | $1,933.25 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-547641
- 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-020784 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-08 is after coverage terminated on 2026-02-14. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 12 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 Summit Regional Medical Center (7959926214). | |
| 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: Summit Regional Medical Center2026-08-08 09:45
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-20 00:06
Attachments
Documents received with the claim
- Itemized billitemized_PA-547641.pdf2 pages
Itemised statement totalling $3515.00 across 2 lines.
- Er reported_report_PA-547641.pdf6 pages
Emergency department record: triage acuity 2, 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 2026-08-08 is after coverage terminated on 2026-02-14.
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.