CLM-2026-031712
Unity Community Hospital, Emergency Medicine. Service 2026-01-19 at emergency room (POS 23). Received 2026-02-27.
Member
Resolved through the identity graph
- Member
- Mateo Barnes
- Member ID
- UHC-54709-71
- Date of birth
- 1954-02-13
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-413003
- Relationship
- Child, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-5709
- Coverage period
- 2025-09-01 to present
- Deductible
- $833.69 of $3,500.0024%
- Out-of-pocket maximum
- $6,441.61 of $14,000.0046%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 2514292657
- Network
- In network
- Rendering NPI
- 2514292657
- Location
- Tampa, FL · TIN 44-4506990
- 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $126.00 | $69.30 | $69.30 | $0.00 | Paid |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | 25 | 1 | 1,2 | $788.00 | $433.40 | $0.00 | $433.40 | Paid |
| Totals | $914.00 | $502.70 | $69.30 | $433.40 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. R07.9 Chest pain, unspecified
- 3. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- Patient account
- PA-242147
- 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-012219 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-19: SELECT-EPO (EPO), effective 2025-09-01. | |
| Timely filing | Pass | Received 39 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 Unity Community Hospital (2514292657). | |
| 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: Unity Community Hospital2026-01-19 17:32
Patient seen for pneumonia, unspecified organism.
Attachments
Documents received with the claim
- Itemized billitemized_PA-242147.pdf2 pages
Itemised statement totalling $914.00 across 2 lines.
- Er reported_report_PA-242147.pdf3 pages
Emergency department record: triage acuity 3, chief complaint pneumonia, unspecified organism.
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031713 | 2026-01-19 | Unity Community Hospital | $914.00 | Needs review |
| CLM-2026-001434 | 2026-01-30 | Lakeside Skin Care Associates | $192.00 | 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.