CLM-2026-034317
Summit Regional Medical Center, Emergency Medicine. Service 2026-01-28 at emergency room (POS 23). Received 2026-02-20.
Member
Resolved through the identity graph
- Member
- Eugene Sanchez
- Member ID
- UHC-18080-63
- Date of birth
- 2000-07-06
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-406186
- Relationship
- Spouse, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-0824
- Coverage period
- 2021-06-01 to present
- Deductible
- $2,143.80 of $3,500.0061%
- Out-of-pocket maximum
- $798.85 of $10,500.008%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 12 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 | $227.00 | $124.85 | $124.85 | $0.00 | Paid |
| 2 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,614.00 | $887.70 | $0.00 | $887.70 | Paid |
| Totals | $1,841.00 | $1,012.55 | $124.85 | $887.70 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. R55 Syncope and collapse
- Patient account
- PA-437649
- 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-014657 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-28: OPTIONS-PPO (PPO), effective 2021-06-01. | |
| Timely filing | Pass | Received 23 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 Center2026-01-28 13:46
Established patient presents with pneumonia, unspecified organism; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-437649.pdf3 pages
Itemised statement totalling $1841.00 across 2 lines.
- Er reported_report_PA-437649.pdf5 pages
Emergency department record: triage acuity 2, chief complaint pneumonia, unspecified organism.
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-2026-009677 | 2026-03-15 | Northgate Internal Medicine Associates | $398.00 | Approved |
| CLM-2026-028062 | 2026-03-14 | Canyon Internal Medicine Associates | $248.00 | 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.