Claims workbench/CLM-2026-000425

Institutional claim · UB-04 · EDI 837I

CLM-2026-000425

Valley Community Hospital, Emergency Medicine. Service 2026-05-10 at emergency room (POS 23). Received 2026-06-03.

PendedOut of networkIdentity on hold: CASE-000983

Billed

$2,369.00

2 lines

Allowed

$1,066.05

if approved

Plan pays

—

Pended

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Pend

IDQ

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Brittany Kelley
Member ID: none on golden record
Date of birth: 1943-09-13
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-415306
Relationship: Self

Coverage and accumulators

Found by name and date of birth

Plan: MEDICARE-ADV-B MA group GRP-0774
Coverage period: 2024-05-01 to present
Deductible: $98.80 of $1,000.0010%
Out-of-pocket maximum: $543.78 of $2,000.0027%
Copays: office $20.00, specialist $50.00, emergency $250.00
Physical therapy visits: 11 of 20 used

Provider

Billing and rendering

Billing provider: Valley Community Hospital
Emergency Medicine · taxonomy 207P00000X
NPI: 3406943738
Network: Out of network
Rendering NPI: 3406943738
Location: Austin, TX · TIN 13-2256808
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	99283 rev 0450	Emergency department visit, moderate severity	—	1	1	$862.00	$387.90	—	—	PendedIDQ
2	99284 rev 0450	Emergency department visit, high severity	—	1	1,2	$1,507.00	$678.15	—	—	PendedIDQ
Totals						$2,369.00	$1,066.05	—	—

Diagnoses (ICD-10-CM)

1. R55 Syncope and collapseprincipal
2. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
3. R10.9 Unspecified abdominal pain

Claim header

Patient account: PA-379137
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 3 needing attention

Check	Result	Code	Detail
Member identity	Fail	IDQ	Member record is in open steward case CASE-000983; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Note		Active on 2026-05-10: MEDICARE-ADV-B (MA), effective 2024-05-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Timely filing	Pass		Received 24 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.

Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Valley Community Hospital2026-05-10 18:49
Patient seen for syncope and collapse.

Attachments

Documents received with the claim

Itemized billitemized_PA-379137.pdf7 pages
Itemised statement totalling $2369.00 across 2 lines.
Er reported_report_PA-379137.pdf3 pages
Emergency department record: triage acuity 2, chief complaint syncope and collapse.

Claim history

Every event on this claim, sealed in the audit chain

Rules enginePended2026-10-21 13:43
Member identity: Member record is in open steward case CASE-000983; payment withheld until the identity is confirmed. Eligibility: Active on 2026-05-10: MEDICARE-ADV-B (MA), effective 2024-05-01. Coverage found by name and date of birth because the claim carried no usable member ID. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queue Member identity