Claims workbench/CLM-2026-008609
Institutional claim · UB-04 · Provider portal

CLM-2026-008609

Summit Regional Medical Center, Emergency Medicine. Service 2026-07-30 at emergency room (POS 23). Received 2026-08-06.

Approved
Billed
$167.00
1 line
Allowed
$91.85
contract rate applied
Plan pays
$0.00
approved
Member owes
$91.85
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Gregory Davis
Member ID
UHC-72859-52
Date of birth
1991-06-07
Identity
Verified2 records, confidence 0.97
Claim record
CLMCLM-406652
Relationship
Spouse, Miami, FL

Coverage and accumulators

Found by member ID

Plan
OPTIONS-PPO PPO group -
Coverage period
2023-03-01 to present
Deductible
$27.69 of $3,500.001%
Out-of-pocket maximum
$4,707.73 of $14,000.0034%
Copays
office $40.00, specialist $50.00, emergency $150.00
Physical therapy visits
11 of 20 used

Provider

Billing and rendering

Billing provider
Summit Regional Medical Center
Emergency Medicine · taxonomy 207P00000X
NPI
7959926214
Network
In network
Rendering NPI
7959926214
Location
Mesa, AZ · TIN 13-8570749
Authorisation / referral
none / none

Service lines

UB-04: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
171046
rev 0320
Chest X-ray, two views—11$167.00$91.85$91.85$0.00Paid
Totals$167.00$91.85$91.85$0.00
Diagnoses (ICD-10-CM)
  • 1. J18.9 Pneumonia, unspecified organismprincipal
Claim header
Patient account
PA-317732
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 0 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-018298 (verified, link confidence 0.97).
EligibilityPassActive on 2026-07-30: OPTIONS-PPO (PPO), effective 2023-03-01.
Timely filingPassReceived 7 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Summit Regional Medical Center (7959926214).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Summit Regional Medical Center2026-07-30 11:58

    Patient seen for pneumonia, unspecified organism.

Attachments

Documents received with the claim

  • Itemized billitemized_PA-317732.pdf8 pages

    Itemised statement totalling $167.00 across 1 line.

  • Er reported_report_PA-317732.pdf2 pages

    Emergency department record: triage acuity 3, chief complaint pneumonia, unspecified organism.

Explanation of benefits

What the member will see

Amount billed
$167.00
Plan discount
$75.15
contracted rate
Plan paid
$0.00
You may owe
$91.85
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-22 12:44
    Clean claim.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

Clean claim: the rules engine approved it, so no AI review was needed.

Examiner decision

Approved by Claims rules engine; an examiner may still override

Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queueMember identity