CLM-2026-030196
Summit Regional Medical Center, Emergency Medicine. Service 2026-04-16 at emergency room (POS 23). Received 2026-05-14.
Member
Resolved through the identity graph
- Member
- Katherine Turner
- Member ID
- UHC-72280-81
- Date of birth
- 1953-12-05
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-402810
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-0466
- Coverage period
- 2023-11-01 to present
- Deductible
- $206.38 of $500.0041%
- Out-of-pocket maximum
- $356.71 of $1,000.0036%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 19 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 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,406.00 | $773.30 | $350.00 | $423.30 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | 25 | 1 | 2 | $186.00 | $102.30 | $0.00 | $102.30 | Paid |
| 3 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $220.00 | $121.00 | $0.00 | $121.00 | Paid |
| Totals | $1,812.00 | $996.60 | $350.00 | $646.60 | ||||||
- 1. R55 Syncope and collapseprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-137045
- 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-012037 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-16: CHOICE-PLUS-PPO (PPO), effective 2023-11-01. | |
| Timely filing | Pass | Received 28 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 Center2026-04-16 17:22
Established patient presents with syncope and collapse; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-137045.pdf7 pages
Itemised statement totalling $1812.00 across 3 lines.
- Er reported_report_PA-137045.pdf6 pages
Emergency department record: triage acuity 3, chief complaint syncope and collapse.
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
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.