CLM-2026-032002
Unity Community Hospital, Emergency Medicine. Service 2026-05-15 at emergency room (POS 23). Received 2026-06-11.
Member
Resolved through the identity graph
- Member
- Maria Medina
- Member ID
- UHC-67207-10
- Date of birth
- 1939-05-27
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-416345
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-1141
- Coverage period
- 2024-01-01 to 2026-04-11
- Deductible
- $803.94 of $3,500.0023%
- Out-of-pocket maximum
- $3,436.05 of $7,000.0049%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 21 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 / REF255720
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 | $1,387.00 | $762.85 | — | — | DeniedCO27 |
| 2 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $2,683.00 | $1,475.65 | — | — | DeniedCO27 |
| Totals | $4,070.00 | $2,238.50 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-633901
- Frequency code
- 1 (original)
- Accident
- Yes
- 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-032432 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-15 is after coverage terminated on 2026-04-11. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 27 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 Hospital2026-05-15 15:47
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-06-11 05:16
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-06-11 08:10
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-633901.pdf2 pages
Itemised statement totalling $4070.00 across 2 lines.
- Er reported_report_PA-633901.pdf3 pages
Emergency department record: triage acuity 3, chief complaint unspecified abdominal pain.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-05-15 is after coverage terminated on 2026-04-11.
Other claims for this member
Same resolved identity
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.