CLM-2026-001945
Summit Community Hospital, Emergency Medicine. Service 2026-02-25 at emergency room (POS 23). Received 2026-03-06.
Member
Resolved through the identity graph
- Member
- Zachary Weber
- Member ID
- UHC-61312-95
- Date of birth
- 1945-01-21
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-408420
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-9617
- Coverage period
- 2024-09-01 to present
- Deductible
- $539.85 of $3,500.0015%
- Out-of-pocket maximum
- $1,098.48 of $7,000.0016%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 7504049959
- Network
- In network
- Rendering NPI
- 7504049959
- Location
- Austin, TX · TIN 97-1362073
- 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 | $2,908.00 | $1,599.40 | $150.00 | $1,449.40 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $184.00 | $101.20 | $0.00 | $101.20 | Paid |
| Totals | $3,092.00 | $1,700.60 | $150.00 | $1,550.60 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- Patient account
- PA-641660
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-017850 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-25: MEDICARE-ADV-A (MA), effective 2024-09-01. | |
| Timely filing | Pass | Received 9 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 Summit Community Hospital (7504049959). | |
| 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 Community Hospital2026-02-25 10:23
Patient seen for pneumonia, unspecified organism.
Attachments
Documents received with the claim
- Itemized billitemized_PA-641660.pdf8 pages
Itemised statement totalling $3092.00 across 2 lines.
- Er reported_report_PA-641660.pdf4 pages
Emergency department record: triage acuity 4, chief complaint pneumonia, unspecified organism.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018048 | 2026-06-20 | Meadow Medical Group | $229.00 | 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.