CLM-2026-002483
Summit Community Hospital, Emergency Medicine. Service 2026-06-01 at emergency room (POS 23). Received 2026-07-01.
Member
Resolved through the identity graph
- Member
- Christian Rojas
- Member ID
- UHC-96374-15
- Date of birth
- 1958-05-15
- Identity
- Verified4 records, confidence 0.98
- Claim record
- CLMCLM-410825
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-7122
- Coverage period
- 2024-05-01 to present
- Deductible
- $369.88 of $500.0074%
- Out-of-pocket maximum
- $257.23 of $1,500.0017%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- 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 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,529.00 | $840.95 | $250.00 | $590.95 | Paid |
| Totals | $1,529.00 | $840.95 | $250.00 | $590.95 | ||||||
- 1. R55 Syncope and collapseprincipal
- 2. J18.9 Pneumonia, unspecified organism
- 3. R10.9 Unspecified abdominal pain
- Patient account
- PA-936894
- Frequency code
- 1 (original)
- Accident
- Yes
- 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-019995 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2026-06-01: SELECT-EPO (EPO), effective 2024-05-01. | |
| Timely filing | Pass | Received 30 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 Hospital2026-06-01 18:16
Established patient presents with syncope and collapse; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-936894.pdf3 pages
Itemised statement totalling $1529.00 across 1 line.
- Er reported_report_PA-936894.pdf3 pages
Emergency department record: triage acuity 4, chief complaint syncope and collapse.
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-2026-019700 | 2026-07-05 | Heritage Family Practice | $521.00 | Approved |
| CLM-2026-029175 | 2026-02-16 | Summit Regional Medical Center | $158.00 | 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.