CLM-2026-008283
Summit Regional Medical Center, Emergency Medicine. Service 2026-09-08 at emergency room (POS 23). Received 2026-09-19.
Member
Resolved through the identity graph
- Member
- Mary Gomez
- Member ID
- UHC-06532-60
- Date of birth
- 1947-11-22
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-425276
- Relationship
- Spouse, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group N/A
- Coverage period
- 2025-01-01 to 2026-02-03
- Deductible
- $327.37 of $1,000.0033%
- Out-of-pocket maximum
- $903.00 of $2,000.0045%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 12 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 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $3,113.00 | $1,712.15 | — | — | DeniedCO27 |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1,2 | $249.00 | $136.95 | — | — | DeniedCO27 |
| Totals | $3,362.00 | $1,849.10 | — | — | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. R10.9 Unspecified abdominal pain
- 3. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- Patient account
- PA-988847
- Frequency code
- 1 (original)
- Accident
- No
- 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-043369 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-08 is after coverage terminated on 2026-02-03. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 11 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 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 Center2026-09-08 10:24
Established patient presents with pneumonia, unspecified organism; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-19 03:56
Attachments
Documents received with the claim
- Itemized billitemized_PA-988847.pdf3 pages
Itemised statement totalling $3362.00 across 2 lines.
- Er reported_report_PA-988847.pdf6 pages
Emergency department record: triage acuity 3, chief complaint pneumonia, unspecified organism.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-09-08 is after coverage terminated on 2026-02-03.
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
Service after coverage termination.