CLM-2026-007157
Summit Community Hospital, Emergency Medicine. Service 2026-06-22 at emergency room (POS 23). Received 2026-07-07.
Member
Resolved through the identity graph
- Member
- Christian Simmonns
- Member ID
- UHC-34681-43
- Date of birth
- 1942-08-17
- Identity
- Verified3 records, confidence 0.93
- Claim record
- CLMCLM-420396
- Relationship
- Spouse, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9523
- Coverage period
- 2021-02-01 to present
- Deductible
- $223.26 of $500.0045%
- Out-of-pocket maximum
- $501.44 of $2,000.0025%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 5 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 / REF494485
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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $166.00 | $91.30 | $91.30 | $0.00 | Paid |
| 2 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 2 | $1,488.00 | $818.40 | $0.00 | $818.40 | Paid |
| Totals | $1,654.00 | $909.70 | $91.30 | $818.40 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- Patient account
- PA-452883
- 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-031724 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-06-22: CORE-HMO (HMO), effective 2021-02-01. | |
| Timely filing | Pass | Received 15 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 Hospital2026-06-22 15:55
Patient seen for pneumonia, unspecified organism.
Attachments
Documents received with the claim
- Itemized billitemized_PA-452883.pdf4 pages
Itemised statement totalling $1654.00 across 2 lines.
- Er reported_report_PA-452883.pdf6 pages
Emergency department record: triage acuity 3, chief complaint pneumonia, unspecified organism.
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-2026-010076 | 2026-04-24 | Mesa Clinical Laboratories | $82.00 | 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.