Claims workbench/CLM-2026-030288
Institutional claim · UB-04 · Provider portal

CLM-2026-030288

Unity Community Hospital, Emergency Medicine. Service 2026-06-14 at emergency room (POS 23). Received 2026-06-19.

Pended
Billed
$2,329.00
3 lines
Allowed
$1,280.95
if approved
Plan pays
—
Pended
Member owes
—
copay / deductible / 10% coinsurance
Rules engine
Pend
CO16
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

The claim record could not be attached to a resolved identity. Resolve it in the steward queue first.

Coverage and accumulators

Found by member ID

Plan
OPTIONS-PPO PPO group GRP-1715
Coverage period
2022-04-01 to present
Deductible
$861.93 of $1,000.0086%
Out-of-pocket maximum
$1,517.97 of $4,000.0038%
Copays
office $30.00, specialist $50.00, emergency $350.00
Physical therapy visits
20 of 20 used

Provider

Billing and rendering

Billing provider
Unity Community Hospital
Emergency Medicine · taxonomy 207P00000X
NPI
5583357806
Network
In network
Rendering NPI
5583357806
Location
Tempe, AZ · TIN 68-0325602
Authorisation / referral
none / none

Service lines

UB-04: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199283
rev 0450
Emergency department visit, moderate severity—11$803.00$441.65——PendedCO16
271046
rev 0320
Chest X-ray, two views—12$230.00$126.50——PendedCO16
399284
rev 0450
Emergency department visit, high severity2511$1,296.00$712.80——PendedCO16
Totals$2,329.00$1,280.95——
Diagnoses (ICD-10-CM)
  • 1. R07.9 Chest pain, unspecifiedprincipal
Claim header
Patient account
PA-612711
Frequency code
1 (original)
Accident
Yes
DRG
—
Admit / discharge
—
Landed
2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

CheckResultCodeDetail
Member identityFailCO16Claim record is not attached to a resolved identity.
Claim lacks information needed for adjudication
EligibilityPassActive on 2026-06-14: OPTIONS-PPO (PPO), effective 2022-04-01.
Timely filingPassReceived 5 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Unity Community Hospital (5583357806).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Unity Community Hospital2026-06-14 14:58

    Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.

Attachments

Documents received with the claim

  • Itemized billitemized_PA-612711.pdf3 pages

    Itemised statement totalling $2329.00 across 3 lines.

  • Er reported_report_PA-612711.pdf2 pages

    Emergency department record: triage acuity 2, chief complaint chest pain, unspecified.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-21 13:43
    Member identity: Claim record is not attached to a resolved identity.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queue