CLM-2026-001702
Meadow Regional Medical Center, Emergency Medicine. Service 2025-12-01 at emergency room (POS 23). Received 2026-01-09.
Member
Resolved through the identity graph
- Member
- Hannah Schultz
- Member ID
- none on golden record
- Date of birth
- 1980-07-03
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-419770
- Relationship
- Child
Coverage and accumulators
Found by name and date of birth
- Plan
- NULL PPO group GRP-2256
- Coverage period
- 2021-03-01 to present
- Deductible
- $533.48 of $1,000.0053%
- Out-of-pocket maximum
- $381.11 of $4,000.0010%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 1905050427
- Network
- In network
- Rendering NPI
- 1905050427
- Location
- Dallas, TX · TIN 71-2312931
- 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 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $2,295.00 | $1,262.25 | — | — | PendedIDQ |
| Totals | $2,295.00 | $1,262.25 | — | — | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-155504
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
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-000823; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2025-12-01: NULL (PPO), effective 2021-03-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 39 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 Meadow Regional Medical Center (1905050427). | |
| 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: “Follow-up for pneumonia, unspecified organism. Plan discussed, medications reconciled. Not”. 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: Meadow Regional Medical Center2025-12-01 13:02
Follow-up for pneumonia, unspecified organism. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-01-09 05:23
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
- Itemized billitemized_PA-155504.pdf7 pages
Itemised statement totalling $2295.00 across 1 line.
- Er reported_report_PA-155504.pdf4 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 enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-000823; payment withheld until the identity is confirmed. Eligibility: Active on 2025-12-01: NULL (PPO), effective 2021-03-01. Coverage found by name and date of birth because the claim carried no usable member ID. Completeness: Documentation incomplete: “Follow-up for pneumonia, unspecified organism. Plan discussed, medications reconciled. Not”.
Other claims for this member
Same resolved identity
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.