CLM-2026-033505
Summit Regional Medical Center, Emergency Medicine. Service 2026-02-27 at emergency room (POS 23). Received 2026-03-03.
Member
Resolved through the identity graph
- Member
- Gabriel Jensen
- Member ID
- UHC-05339-10
- Date of birth
- 1992-06-17
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-411475
- Relationship
- Spouse, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-0748
- Coverage period
- 2023-04-01 to present
- Deductible
- $155.09 of $500.0031%
- Out-of-pocket maximum
- $260.29 of $1,500.0017%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 1269847210
- Network
- In network
- Rendering NPI
- 1269847210
- Location
- Mesa, AZ · TIN 62-8021640
- 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 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,373.00 | $755.15 | $150.00 | $605.15 | Paid |
| Totals | $1,373.00 | $755.15 | $150.00 | $605.15 | ||||||
- 1. R55 Syncope and collapseprincipal
- 2. J18.9 Pneumonia, unspecified organism
- Patient account
- PA-375303
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-017230 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-27: NULL (PPO), effective 2023-04-01. | |
| Timely filing | Pass | Received 4 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 (1269847210). | |
| 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 Center2026-02-27 17:23
Patient seen for syncope and collapse.
Attachments
Documents received with the claim
- Itemized billitemized_PA-375303.pdf4 pages
Itemised statement totalling $1373.00 across 1 line.
- Er reported_report_PA-375303.pdf2 pages
Emergency department record: triage acuity 3, chief complaint syncope and collapse.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012916 | 2026-08-30 | Pinecrest Medical Group | $2,572.00 | 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.