Claims workbench/CLM-2026-006544

Institutional claim · UB-04 · EDI 837I

CLM-2026-006544

Summit Regional Medical Center, Emergency Medicine. Service 2026-03-03 at emergency room (POS 23). Received 2026-07-13.

Denied

Billed

$1,982.00

1 line

Allowed

$1,090.10

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Deny

CO29

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Jonathan Kelly
Member ID: UHC-10931-15
Date of birth: 1985-10-27
Identity: Verified4 records, confidence 0.97
Claim record: CLMCLM-422881
Relationship: Self, Phoenix, AZ

Coverage and accumulators

Found by member ID

Plan: SELECT-EPO EPO group GRP-8879
Coverage period: 2025-09-01 to present
Deductible: $162.19 of $2,500.006%
Out-of-pocket maximum: $2,018.74 of $5,000.0040%
Copays: office $25.00, specialist $60.00, emergency $150.00
Physical therapy visits: 11 of 20 used

Provider

Billing and rendering

Billing provider: Summit Regional Medical Center
Emergency Medicine · taxonomy 207P00000X
NPI: 7959926214
Network: In network
Rendering NPI: 7959926214
Location: Mesa, AZ · TIN 13-8570749
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	99285 rev 0450	Emergency department visit, high severity with threat to life	—	1	1	$1,982.00	$1,090.10	—	—	DeniedCO29
Totals						$1,982.00	$1,090.10	—	—

Diagnoses (ICD-10-CM)

1. J18.9 Pneumonia, unspecified organismprincipal
2. R55 Syncope and collapse

Claim header

Patient account: PA-636288
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-010588 (verified, link confidence 0.97).
Eligibility	Pass		Active on 2026-03-03: SELECT-EPO (EPO), effective 2025-09-01.
Timely filing	Fail	CO29	Received 132 days after the last date of service (limit 90). Time limit for filing has expired
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 Regional Medical Center (7959926214).
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.

Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Summit Regional Medical Center2026-03-03 11:25
Established patient presents with pneumonia, unspecified organism; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-07-13 06:19
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
AdministrativeExaminer: R. Patel (Claims Examiner II)2026-07-13 08:11
Reviewed with the member's history on file. Holding for the items listed above.

Attachments

Documents received with the claim

Itemized billitemized_PA-636288.pdf8 pages
Itemised statement totalling $1982.00 across 1 line.
Er reported_report_PA-636288.pdf5 pages
Emergency department record: triage acuity 4, chief complaint pneumonia, unspecified organism.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Timely filing: Received 132 days after the last date of service (limit 90).

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-008239	2026-05-21	Desert Primary Care Associates	$365.00	Needs review
CLM-2026-008238	2026-05-21	Desert Primary Care Associates	$365.00	Approved
CLM-2026-008252	2026-01-10	Pinecrest Regional Medical Center	$1,175.00	Needs review

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

DeniedCO29scenario: Late filing

Received after the timely-filing limit.

Review queue Member identity