CLM-2026-003778
Summit Community Hospital, Emergency Medicine. Service 2026-04-19 at emergency room (POS 23). Received 2026-05-14.
Member
Resolved through the identity graph
- Member
- Billy Olson
- Member ID
- UHC-87272-66
- Date of birth
- 1974-06-21
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-408213
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-6840
- Coverage period
- 2022-02-01 to present
- Deductible
- $382.00 of $1,000.0038%
- Out-of-pocket maximum
- $588.78 of $4,000.0015%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 5 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 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $247.00 | $135.85 | $135.85 | $0.00 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $152.00 | $83.60 | $0.00 | $83.60 | Paid |
| 3 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $802.00 | $441.10 | $0.00 | $441.10 | Paid |
| Totals | $1,201.00 | $660.55 | $135.85 | $524.70 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. J18.9 Pneumonia, unspecified organism
- 3. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- Patient account
- PA-411812
- 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-030613 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-04-19: SELECT-EPO (EPO), effective 2022-02-01. | |
| Timely filing | Pass | Received 25 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 Hospital2026-04-19 13:08
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-05-14 04:55
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-05-14 11:43
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-411812.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
- Itemized billitemized_PA-411812.pdf5 pages
Itemised statement totalling $1201.00 across 3 lines.
- Er reported_report_PA-411812.pdf3 pages
Emergency department record: triage acuity 4, chief complaint unspecified abdominal pain.
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-2026-020711 | 2026-05-11 | Meadow Primary Care Associates | $203.00 | Needs review |
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
Authorisation must be confirmed with UM before payment.