CLM-2026-004978
Summit Community Hospital, Emergency Medicine. Service 2026-05-05 at emergency room (POS 23). Received 2026-06-12.
Member
Resolved through the identity graph
- Member
- Kevin Gray
- Member ID
- UHC-41944-42
- Date of birth
- 1944-07-03
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-401247
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-2617
- Coverage period
- 2021-03-01 to present
- Deductible
- $849.03 of $2,500.0034%
- Out-of-pocket maximum
- $1,832.24 of $10,000.0018%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 2 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 / REF844937
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 | $141.00 | $77.55 | — | — | Review |
| Totals | $141.00 | $77.55 | — | — | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- Patient account
- PA-745140
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-034574 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-05: CORE-HMO (HMO), effective 2021-03-01. | |
| Timely filing | Pass | Received 38 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 | Review | CO16 | Documentation incomplete: “Established patient presents with pneumonia, unspecified organism; symptoms reviewed and v”. 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: Summit Community Hospital2026-05-05 09:08
Established patient presents with pneumonia, unspecified organism; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-06-12 05:17
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
- Itemized billitemized_PA-745140.pdf4 pages
Itemised statement totalling $141.00 across 1 line.
- Er reported_report_PA-745140.pdf6 pages
Emergency department record: triage acuity 3, chief complaint pneumonia, unspecified organism.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Established patient presents with pneumonia, unspecified organism; symptoms reviewed and v”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025111 | 2026-08-31 | Lakeside Physical Therapy | $180.00 | Approved |
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.