CLM-2026-010081
Valley Community Hospital, Emergency Medicine. Service 2026-04-22 at emergency room (POS 23). Received 2026-05-07.
Member
Resolved through the identity graph
- Member
- James Delgado
- Member ID
- UHC-33344-70
- Date of birth
- 1977-12-02
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-402541
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-6493
- Coverage period
- 2021-02-01 to present
- Deductible
- $2,622.07 of $3,500.0075%
- Out-of-pocket maximum
- $1,060.27 of $7,000.0015%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 7 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 / 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 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $218.00 | $98.10 | $98.10 | $0.00 | Paid |
| 2 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 2 | $1,091.00 | $490.95 | $0.00 | $490.95 | Paid |
| Totals | $1,309.00 | $589.05 | $98.10 | $490.95 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-843740
- Frequency code
- 1 (original)
- Accident
- Yes
- 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-018511 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-04-22: OPTIONS-PPO (PPO), effective 2021-02-01. | |
| Timely filing | Pass | Received 15 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Hospital2026-04-22 14:09
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-843740.pdf2 pages
Itemised statement totalling $1309.00 across 2 lines.
- Er reported_report_PA-843740.pdf6 pages
Emergency department record: triage acuity 2, chief complaint chest pain, unspecified.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020844 | 2026-09-24 | Mesa Physical Therapy | $359.00 | Denied |
| CLM-2026-020843 | 2026-09-24 | Mesa Physical Therapy | $359.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.