CLM-2026-029818
Summit Regional Medical Center, Emergency Medicine. Service 2026-01-15 at emergency room (POS 23). Received 2026-01-20.
Member
Resolved through the identity graph
- Member
- Kenneth Reynolds
- Member ID
- UHC-25022-82
- Date of birth
- 1975-11-04
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-400272
- Relationship
- Spouse, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8555
- Coverage period
- 2024-01-01 to 2026-01-17
- Deductible
- $208.96 of $500.0042%
- Out-of-pocket maximum
- $429.84 of $1,500.0029%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 1269847210
- Network
- In network
- Rendering NPI
- 1269847210
- Location
- Mesa, AZ · TIN 62-8021640
- 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 | $1,625.00 | $893.75 | — | — | Review |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | 25 | 1 | 1 | $762.00 | $419.10 | — | — | Review |
| Totals | $2,387.00 | $1,312.85 | — | — | ||||||
- 1. R55 Syncope and collapseprincipal
- Patient account
- PA-915427
- 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-006118 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-15: CHOICE-PLUS-PPO (PPO), effective 2024-01-01, terms 2026-01-17. | |
| Timely filing | Pass | Received 5 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 (1269847210). | |
| 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: “Established patient presents with syncope and collapse; symptoms reviewed and vitals withi”. 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: Summit Regional Medical Center2026-01-15 12:45
Established patient presents with syncope and collapse; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-01-20 02:46
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
- Itemized billitemized_PA-915427.pdf2 pages
Itemised statement totalling $2387.00 across 2 lines.
- Er reported_report_PA-915427.pdf3 pages
Emergency department record: triage acuity 3, chief complaint syncope and collapse.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Completeness: Documentation incomplete: “Established patient presents with syncope and collapse; symptoms reviewed and vitals withi”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011428 | 2026-02-20 | Unity Counseling Center | $405.00 | Denied |
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.