CLM-2026-007944
Valley Community Hospital, Emergency Medicine. Service 2026-05-28 at emergency room (POS 23). Received 2026-10-15.
Member
Resolved through the identity graph
- Member
- Ryan Walker
- Member ID
- UHC-79552-94
- Date of birth
- 1979-07-19
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-428260
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-6462
- Coverage period
- 2025-10-01 to present
- Deductible
- $120.86 of $3,500.003%
- Out-of-pocket maximum
- $3,554.71 of $14,000.0025%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 3406943738
- Network
- Out of network
- Rendering NPI
- 3406943738
- Location
- Austin, TX · TIN 13-2256808
- Authorisation / referral
- none / REF832559
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 | $1,062.00 | $584.10 | — | — | DeniedCO29 |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1,2 | $225.00 | $123.75 | — | — | DeniedCO29 |
| Totals | $1,287.00 | $707.85 | — | — | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. R55 Syncope and collapse
- Patient account
- PA-257648
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-013529 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-28: NAVIGATE-HMO (HMO), effective 2025-10-01. | |
| Timely filing | Fail | CO29 | Received 140 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 | Review | NET | Out-of-network emergency visit. Payable at the in-network level if the prudent-layperson standard is met; review the ED record. Out-of-network provider |
| 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 Community Hospital2026-05-28 16:28
Follow-up for pneumonia, unspecified organism. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-10-15 06:12
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
- Itemized billitemized_PA-257648.pdf6 pages
Itemised statement totalling $1287.00 across 2 lines.
- Er reported_report_PA-257648.pdf4 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 140 days after the last date of service (limit 90). Provider network: Out-of-network emergency visit. Payable at the in-network level if the prudent-layperson standard is met; review the ED record.
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.