CLM-2026-007537
Valley Regional Medical Center, Emergency Medicine. Service 2026-08-16 at emergency room (POS 23). Received 2026-09-10.
Member
Resolved through the identity graph
- Member
- Cheryl Gray
- Member ID
- UHC-21057-88
- Date of birth
- 1950-06-23
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-424185
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2077
- Coverage period
- 2023-09-01 to 2026-08-12
- Deductible
- $338.96 of $500.0068%
- Out-of-pocket maximum
- $509.11 of $1,500.0034%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 11 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 | $627.00 | $344.85 | — | — | DeniedCO27 |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1,2 | $162.00 | $89.10 | — | — | DeniedCO27 |
| Totals | $789.00 | $433.95 | — | — | ||||||
- 1. S93.401A Sprain of unspecified ligament of right ankle, initial encounterprincipal
- 2. R10.9 Unspecified abdominal pain
- 3. J18.9 Pneumonia, unspecified organism
- Patient account
- PA-623308
- Frequency code
- 1 (original)
- Accident
- Yes
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-013278 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-16 is after coverage terminated on 2026-08-12. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 25 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 Center2026-08-16 13:28
Established patient presents with sprain of unspecified ligament of right ankle, initial encounter; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-10 00:44
Attachments
Documents received with the claim
- Itemized billitemized_PA-623308.pdf6 pages
Itemised statement totalling $789.00 across 2 lines.
- Er reported_report_PA-623308.pdf5 pages
Emergency department record: triage acuity 3, chief complaint sprain of unspecified ligament of right ankle, initial encounter.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-08-16 is after coverage terminated on 2026-08-12.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032976 | 2026-07-03 | Unity Community Hospital | $2,403.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.