CLM-2026-034350
Sunrise Community Hospital, Emergency Medicine. Service 2025-12-14 at emergency room (POS 23). Received 2026-01-28.
Member
Resolved through the identity graph
- Member
- Catherine Hart
- Member ID
- UHC-18151-19
- Date of birth
- 1963-09-20
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-419384
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-3663
- Coverage period
- 2025-04-01 to present
- Deductible
- $1,927.23 of $2,500.0077%
- Out-of-pocket maximum
- $4,611.23 of $10,000.0046%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 5 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 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,298.00 | $713.90 | — | — | Review |
| Totals | $1,298.00 | $713.90 | — | — | ||||||
- 1. S93.401A Sprain of unspecified ligament of right ankle, initial encounterprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-574453
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-008446 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2025-12-14: MEDICARE-ADV-A (MA), effective 2025-04-01. | |
| Timely filing | Pass | Received 45 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 | Review | CO16 | Documentation incomplete: “Established patient presents with sprain of unspecified ligament of right ankle, initial e”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Community Hospital2025-12-14 15:36
Established patient presents with sprain of unspecified ligament of right ankle, initial encounter; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-01-28 01:47
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-01-28 08:50
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-574453.pdf3 pages
Itemised statement totalling $1298.00 across 1 line.
- Er reported_report_PA-574453.pdf5 pages
Emergency department record: triage acuity 4, chief complaint sprain of unspecified ligament of right ankle, initial encounter.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Established patient presents with sprain of unspecified ligament of right ankle, initial e”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020085 | 2026-09-01 | Sunrise Family Practice | $2,291.00 | Needs review |
| CLM-2026-018350 | 2026-06-15 | Northgate Reference Lab | $72.00 | Approved |
| CLM-2026-024328 | 2026-05-14 | Desert Reference Lab | $36.00 | Approved |
| CLM-2026-015118 | 2026-04-23 | Northgate Primary Care Associates | $23.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.