CLM-2026-006853
Summit Community Hospital, Emergency Medicine. Service 2026-04-17 at emergency room (POS 23). Received 2026-04-20.
Member
Resolved through the identity graph
- Member
- Vicky Cook
- Member ID
- UHC-08669-16
- Date of birth
- 1987-07-25
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-423396
- Relationship
- Spouse, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-1322
- Coverage period
- 2021-02-01 to 2026-04-21
- Deductible
- $2,247.66 of $2,500.0090%
- Out-of-pocket maximum
- $908.75 of $7,500.0012%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 7 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 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,726.00 | $949.30 | $350.00 | $599.30 | Paid |
| Totals | $1,726.00 | $949.30 | $350.00 | $599.30 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-472495
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-011740 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-17: MEDICARE-ADV-B (MA), effective 2021-02-01, terms 2026-04-21. | |
| Timely filing | Pass | Received 3 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 Hospital2026-04-17 15:08
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-472495.pdf9 pages
Itemised statement totalling $1726.00 across 1 line.
- Er reported_report_PA-472495.pdf4 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 engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032936 | 2026-07-16 | Valley Bone and Joint Center | $35,201.00 | Denied |
| CLM-2026-011815 | 2026-05-18 | Canyon Heart Institute | $7,707.00 | Denied |
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.