CLM-2026-005703
Valley Regional Medical Center, Emergency Medicine. Service 2026-03-10 at emergency room (POS 23). Received 2026-03-20.
Member
Resolved through the identity graph
- Member
- Sharon Stevens
- Member ID
- UHC-69450-62
- Date of birth
- 1948-08-04
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-425736
- Relationship
- Child, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3137
- Coverage period
- 2023-12-01 to present
- Deductible
- $945.29 of $1,500.0063%
- Out-of-pocket maximum
- $1,838.69 of $4,500.0041%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 2408607978
- Network
- In network
- Rendering NPI
- 2408607978
- Location
- Austin, TX · TIN 89-0699789
- 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 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $810.00 | $445.50 | $250.00 | $195.50 | Paid |
| 2 | 96374 rev 0260 | IV push, single drug | — | 1 | 1,2 | $201.00 | $110.55 | $0.00 | $110.55 | Paid |
| Totals | $1,011.00 | $556.05 | $250.00 | $306.05 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-360017
- 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-018785 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-10: OPTIONS-PPO (PPO), effective 2023-12-01. | |
| Timely filing | Pass | Received 10 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 Valley Regional Medical Center (2408607978). | |
| 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 Regional Medical Center2026-03-10 12:09
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-360017.pdf5 pages
Itemised statement totalling $1011.00 across 2 lines.
- Er reported_report_PA-360017.pdf2 pages
Emergency department record: triage acuity 3, 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-2026-014596 | 2026-03-14 | Pinecrest Internal Medicine Associates | $239.00 | 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.