CLM-2026-010220
Summit Regional Medical Center, Emergency Medicine. Service 2026-05-04 at emergency room (POS 23). Received 2026-05-12.
Member
Resolved through the identity graph
- Member
- Gerald Pierce
- Member ID
- UHC-41868-23
- Date of birth
- 1996-11-14
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-407239
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-1527
- Coverage period
- 2025-08-01 to present
- Deductible
- $1,260.71 of $1,500.0084%
- Out-of-pocket maximum
- $1,237.40 of $3,000.0041%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 3 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 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $231.00 | $127.05 | — | — | PendedIDQ |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $1,010.00 | $555.50 | — | — | PendedIDQ |
| Totals | $1,241.00 | $682.55 | — | — | ||||||
- 1. S93.401A Sprain of unspecified ligament of right ankle, initial encounterprincipal
- 2. J18.9 Pneumonia, unspecified organism
- Patient account
- PA-935700
- 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 | Fail | IDQ | Member record is in open steward case CASE-000722; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-05-04: NULL (PPO), effective 2025-08-01. | |
| Timely filing | Pass | Received 8 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 Center2026-05-04 18:17
Patient seen for sprain of unspecified ligament of right ankle, initial encounter.
Attachments
Documents received with the claim
- Itemized billitemized_PA-935700.pdf2 pages
Itemised statement totalling $1241.00 across 2 lines.
- Er reported_report_PA-935700.pdf5 pages
Emergency department record: triage acuity 4, chief complaint sprain of unspecified ligament of right ankle, initial encounter.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-000722; payment withheld until the identity is confirmed.
Other claims for this member
Same resolved identity
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
Clean claim, priced at contract rate.