CLM-2026-033034
Sunrise Community Hospital, Emergency Medicine. Service 2026-08-20 at emergency room (POS 23). Received 2026-09-30.
Member
Resolved through the identity graph
- Member
- Jose Walker
- Member ID
- UHC-06820-75
- Date of birth
- 1967-09-02
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-432588
- Relationship
- Spouse, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-6531
- Coverage period
- 2025-10-01 to present
- Deductible
- $1,387.80 of $2,500.0056%
- Out-of-pocket maximum
- $860.96 of $5,000.0017%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 2310065109
- Network
- In network
- Rendering NPI
- 2310065109
- Location
- Mesa, AZ · TIN 51-3085459
- 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 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $1,671.00 | $919.05 | $150.00 | $769.05 | Paid |
| Totals | $1,671.00 | $919.05 | $150.00 | $769.05 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- Patient account
- PA-725910
- 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-004993 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-08-20: MEDICARE-ADV-B (MA), effective 2025-10-01. | |
| Timely filing | Pass | Received 41 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 Sunrise Community Hospital (2310065109). | |
| 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: Sunrise Community Hospital2026-08-20 13:16
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-725910.pdf4 pages
Itemised statement totalling $1671.00 across 1 line.
- Er reported_report_PA-725910.pdf5 pages
Emergency department record: triage acuity 3, chief complaint unspecified abdominal pain.
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-2026-001033 | 2026-05-22 | Meadow Internal Medicine Associates | $2,539.00 | Needs review |
| CLM-2026-021049 | 2026-04-16 | Unity Internal Medicine Associates | $763.00 | Approved |
| CLM-2026-027897 | 2025-12-18 | Cornerstone Internal Medicine Associates | $2,064.00 | Needs review |
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.