CLM-2026-001060
Summit Regional Medical Center, Emergency Medicine. Service 2025-10-13 at emergency room (POS 23). Received 2026-03-07.
Member
Resolved through the identity graph
- Member
- Nicholas Johnson
- Member ID
- UHC-82744-56
- Date of birth
- 1950-06-24
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-415469
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3855
- Coverage period
- 2025-05-01 to present
- Deductible
- $97.52 of $2,500.004%
- Out-of-pocket maximum
- $1,625.60 of $5,000.0033%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 3973431752
- Network
- In network
- Rendering NPI
- 3973431752
- Location
- Nashville, TN · TIN 74-3643207
- Authorisation / referral
- none / REF657356
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 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $3,144.00 | $1,729.20 | — | — | DeniedCO29 |
| Totals | $3,144.00 | $1,729.20 | — | — | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- Patient account
- PA-761308
- Frequency code
- 1 (original)
- Accident
- No
- 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-017954 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-10-13: CORE-HMO (HMO), effective 2025-05-01. | |
| Timely filing | Fail | CO29 | Received 145 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 (3973431752). | |
| 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 Center2025-10-13 18:42
Patient seen for pneumonia, unspecified organism.
- SystemSystem: Claims system2026-03-07 04:10
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-03-07 12:00
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-761308.pdf8 pages
Itemised statement totalling $3144.00 across 1 line.
- Er reported_report_PA-761308.pdf5 pages
Emergency department record: triage acuity 2, chief complaint pneumonia, unspecified organism.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 145 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-027000 | 2026-06-05 | Desert Medical Group | $716.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Received after the timely-filing limit.