CLM-2026-029802
Sunrise Community Hospital, Emergency Medicine. Service 2026-06-20 at emergency room (POS 23). Received 2026-06-22.
Member
Resolved through the identity graph
- Member
- Olivia Bailey
- Member ID
- UHC-51764-25
- Date of birth
- 1953-08-06
- Identity
- Verified3 records, confidence 0.94
- Claim record
- CLMCLM-426309
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-8960
- Coverage period
- 2023-02-01 to present
- Deductible
- $430.26 of $500.0086%
- Out-of-pocket maximum
- $629.19 of $1,500.0042%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 7 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 / REF676258
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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $120.00 | $66.00 | $66.00 | $0.00 | Paid |
| 2 | 99284 rev 0450 | Emergency department visit, high severity | 25 | 1 | 1 | $1,371.00 | $754.05 | $0.00 | $754.05 | Paid |
| 3 | 99283 rev 0450 | Emergency department visit, moderate severity | 25 | 1 | 2 | $633.00 | $348.15 | $0.00 | $348.15 | Paid |
| Totals | $2,124.00 | $1,168.20 | $66.00 | $1,102.20 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-246374
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-010013 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2026-06-20: NAVIGATE-HMO (HMO), effective 2023-02-01. | |
| Timely filing | Pass | Received 2 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 Hospital2026-06-20 18:25
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-246374.pdf6 pages
Itemised statement totalling $2124.00 across 3 lines.
- Er reported_report_PA-246374.pdf3 pages
Emergency department record: triage acuity 3, chief complaint unspecified abdominal pain.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029662 | 2026-07-20 | Sunrise Counseling Center | $228.00 | 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.