CLM-2026-007582
Summit Regional Medical Center, Emergency Medicine. Service 2025-09-23 at emergency room (POS 23). Received 2026-04-01.
Member
Resolved through the identity graph
- Member
- Natalie Collins
- Member ID
- UHC-61521-40
- Date of birth
- 1957-07-26
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-414091
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-9487
- Coverage period
- 2022-07-01 to present
- Deductible
- $2,227.46 of $3,500.0064%
- Out-of-pocket maximum
- $2,048.01 of $7,000.0029%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 3973431752
- Network
- In network
- Rendering NPI
- 3973431752
- Location
- Nashville, TN · TIN 74-3643207
- 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 | $680.00 | $374.00 | — | — | DeniedCO29 |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 2 | $213.00 | $117.15 | — | — | DeniedCO29 |
| 3 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $227.00 | $124.85 | — | — | DeniedCO29 |
| Totals | $1,120.00 | $616.00 | — | — | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. R55 Syncope and collapse
- Patient account
- PA-847422
- 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-015781 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-09-23: NULL (PPO), effective 2022-07-01. | |
| Timely filing | Fail | CO29 | Received 190 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 (3973431752). | |
| 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 Regional Medical Center2025-09-23 11:40
Patient seen for pneumonia, unspecified organism.
- SystemSystem: Claims system2026-04-01 01:54
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-04-01 13:35
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-847422.pdf3 pages
Itemised statement totalling $1120.00 across 3 lines.
- Er reported_report_PA-847422.pdf3 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 13:43Timely filing: Received 190 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
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
Received after the timely-filing limit.