CLM-2026-034505
Sunrise Community Hospital, Emergency Medicine. Service 2026-01-13 at emergency room (POS 23). Received 2026-02-20.
Member
Resolved through the identity graph
- Member
- Mary Howard
- Member ID
- UHC-25750-60
- Date of birth
- 1951-10-22
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-420554
- Relationship
- Child, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-7776
- Coverage period
- 2022-12-01 to present
- Deductible
- $1,146.36 of $1,500.0076%
- Out-of-pocket maximum
- $680.69 of $6,000.0011%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 2411187117
- Network
- Out of network
- Rendering NPI
- 2411187117
- Location
- Tempe, AZ · TIN 19-3902018
- 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 | $207.00 | $93.15 | $93.15 | $0.00 | Paid |
| 2 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $183.00 | $82.35 | $0.00 | $82.35 | Paid |
| Totals | $390.00 | $175.50 | $93.15 | $82.35 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-389614
- Frequency code
- 1 (original)
- Accident
- Yes
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-014500 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-01-13: OPTIONS-PPO (PPO), effective 2022-12-01. | |
| 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Hospital2026-01-13 13:49
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-389614.pdf4 pages
Itemised statement totalling $390.00 across 2 lines.
- Er reported_report_PA-389614.pdf2 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 engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012014 | 2026-07-27 | Summit Diagnostic Imaging | $3,012.00 | Approved |
| CLM-2026-033760 | 2026-03-26 | Unity Primary Care Associates | $205.00 | 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.