CLM-2026-033672
Summit Regional Medical Center, Emergency Medicine. Service 2026-07-21 at emergency room (POS 23). Received 2026-08-28.
Member
Resolved through the identity graph
- Member
- Jesse Wood
- Member ID
- UHC-53279-40
- Date of birth
- 1995-03-01
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-419051
- Relationship
- Spouse, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6771
- Coverage period
- 2023-11-01 to present
- Deductible
- $372.61 of $3,500.0011%
- Out-of-pocket maximum
- $1,394.59 of $14,000.0010%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 11 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 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $201.00 | $110.55 | $110.55 | $0.00 | Paid |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $726.00 | $399.30 | $0.00 | $399.30 | Paid |
| Totals | $927.00 | $509.85 | $110.55 | $399.30 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-956140
- 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-023756 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-21: NULL (PPO), effective 2023-11-01. | |
| Timely filing | Pass | Received 38 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 Center2026-07-21 16:50
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-956140.pdf2 pages
Itemised statement totalling $927.00 across 2 lines.
- Er reported_report_PA-956140.pdf6 pages
Emergency department record: triage acuity 4, 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-2026-001078 | 2026-07-17 | Riverside GI Associates | $2,570.00 | 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.