CLM-2026-031940
Summit Regional Medical Center, Emergency Medicine. Service 2026-08-12 at emergency room (POS 23). Received 2026-08-15.
Member
Resolved through the identity graph
- Member
- Aisha Larson
- Member ID
- UHC-69901-39
- Date of birth
- 1949-09-22
- Identity
- Verified6 records, confidence 0.97
- Claim record
- CLMCLM-429222
- Relationship
- Child, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1530
- Coverage period
- 2024-05-01 to 2026-08-02
- Deductible
- $1,290.67 of $2,500.0052%
- Out-of-pocket maximum
- $2,222.91 of $10,000.0022%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 6 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $157.00 | $86.35 | — | — | DeniedCO27 |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $862.00 | $474.10 | — | — | DeniedCO27 |
| 3 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,290.00 | $709.50 | — | — | DeniedCO27 |
| Totals | $2,309.00 | $1,269.95 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-341889
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-024306 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-12 is after coverage terminated on 2026-08-02. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 3 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 Center2026-08-12 12:21
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-15 01:37
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-08-15 09:00
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-341889.pdf4 pages
Itemised statement totalling $2309.00 across 3 lines.
- Er reported_report_PA-341889.pdf5 pages
Emergency department record: triage acuity 2, chief complaint unspecified abdominal pain.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-12 is after coverage terminated on 2026-08-02.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032788 | 2026-07-23 | Northgate Counseling Center | $233.00 | Approved |
| CLM-2026-021245 | 2026-08-19 | Unity Community Hospital | $3,791.00 | Denied |
| CLM-2026-000469 | 2026-08-09 | Unity Medical Group | $220.00 | Denied |
| CLM-2026-006549 | 2026-03-24 | Canyon Cardiovascular Associates | $535.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.