CLM-2026-005002
Valley Community Hospital, Emergency Medicine. Service 2025-12-18 at emergency room (POS 23). Received 2026-01-14.
Member
Resolved through the identity graph
- Member
- Amy Lawrence
- Member ID
- UHC-73297-66
- Date of birth
- 2003-09-23
- Identity
- Verified7 records, confidence 0.96
- Claim record
- CLMCLM-415301
- Relationship
- Child, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-6488
- Coverage period
- 2022-07-01 to 2026-05-16
- Deductible
- $736.52 of $2,500.0029%
- Out-of-pocket maximum
- $881.01 of $7,500.0012%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 3406943738
- Network
- Out of network
- Rendering NPI
- 3406943738
- Location
- Austin, TX · TIN 13-2256808
- Authorisation / referral
- none / REF797590
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 | $181.00 | $99.55 | — | — | Review |
| Totals | $181.00 | $99.55 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-383099
- 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-004287 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2025-12-18: CORE-HMO (HMO), effective 2022-07-01, terms 2026-05-16. | |
| Timely filing | Pass | Received 27 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 | Review | NET | Out-of-network emergency visit. Payable at the in-network level if the prudent-layperson standard is met; review the ED record. Out-of-network provider |
| 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: Valley Community Hospital2025-12-18 09:13
Patient seen for chest pain, unspecified. Patient presented to the nearest emergency department with acute symptoms; care could not safely be delayed to reach an in-network facility.
- SystemSystem: Claims system2026-01-14 05:47
Out-of-network emergency visit. Emergency services are payable at the in-network level when the prudent-layperson standard is met.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-01-14 11:39
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-383099.pdf2 pages
Itemised statement totalling $181.00 across 1 line.
- Er reported_report_PA-383099.pdf2 pages
Emergency department record: triage acuity 3, chief complaint chest pain, unspecified.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Provider network: Out-of-network emergency visit. Payable at the in-network level if the prudent-layperson standard is met; review the ED record.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-003534 | 2026-07-17 | Riverside Clinical Laboratories | $81.00 | Denied |
| CLM-2026-028912 | 2026-05-17 | Meadow Cardiovascular Associates | $1,827.00 | Denied |
| CLM-2026-023157 | 2026-01-11 | Canyon Primary Care Associates | $279.00 | 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
Emergency: payable at in-network level.