CLM-2026-008980
Summit Community Hospital, Emergency Medicine. Service 2026-03-17 at emergency room (POS 23). Received 2026-07-23.
Member
Resolved through the identity graph
- Member
- Donna Ramos
- Member ID
- UHC-64152-85
- Date of birth
- 1995-10-06
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-427823
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-9368
- Coverage period
- 2025-06-01 to present
- Deductible
- $1,506.55 of $3,500.0043%
- Out-of-pocket maximum
- $1,056.33 of $10,500.0010%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 2 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 / REF474229
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 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $154.00 | $84.70 | — | — | DeniedCO29 |
| Totals | $154.00 | $84.70 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-935242
- 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-027937 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-17: NAVIGATE-HMO (HMO), effective 2025-06-01. | |
| Timely filing | Fail | CO29 | Received 128 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 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 Hospital2026-03-17 13:19
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-23 06:21
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-07-23 11:26
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-935242.pdf9 pages
Itemised statement totalling $154.00 across 1 line.
- Er reported_report_PA-935242.pdf4 pages
Emergency department record: triage acuity 3, chief complaint unspecified abdominal pain.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 128 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025797 | 2026-07-17 | Cornerstone Internal Medicine Associates | $84.00 | Approved |
| CLM-2026-020847 | 2026-07-24 | Lakeside Clinical Laboratories | $141.00 | Approved |
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.