CLM-2026-008148
Summit Community Hospital, Emergency Medicine. Service 2026-02-23 at emergency room (POS 23). Received 2026-03-19.
Member
Resolved through the identity graph
- Member
- Christine Ortiz
- Member ID
- UHC-56393-98
- Date of birth
- 1975-01-27
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-411853
- Relationship
- Child, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5674
- Coverage period
- 2021-01-01 to present
- Deductible
- $403.96 of $1,500.0027%
- Out-of-pocket maximum
- $1,339.37 of $6,000.0022%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 19 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 | $1,660.00 | $913.00 | — | — | Review |
| Totals | $1,660.00 | $913.00 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-916000
- Frequency code
- 7 (replacement)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 12 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-010128 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-23: CHOICE-PLUS-PPO (PPO), effective 2021-01-01. | |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Replacement claim | Review | REPL | Frequency code 7 replaces CLM-2026-008147; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission |
| 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 Hospital2026-02-23 17:48
Patient seen for chest pain, unspecified. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
- SystemSystem: Claims system2026-03-19 01:18
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
Attachments
Documents received with the claim
- Itemized billitemized_PA-916000.pdf8 pages
Itemised statement totalling $1660.00 across 1 line.
- Er reported_report_PA-916000.pdf4 pages
Emergency department record: triage acuity 4, chief complaint chest pain, unspecified.
- Corrected claimcorrected_CLM-2026-008147.pdf1 page
Provider cover letter requesting replacement of CLM-2026-008147.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Replacement claim: Frequency code 7 replaces CLM-2026-008147; the original must be voided when this adjudicates.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-008147 | 2026-02-23 | Summit Community Hospital | $1,660.00 | Approved |
| CLM-2026-022850 | 2025-12-31 | Pinecrest Regional Medical Center | $3,714.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Replacement claim supersedes the original.