CLM-2026-010377
Summit Regional Medical Center, Emergency Medicine. Service 2026-07-24 at emergency room (POS 23). Received 2026-08-06.
Member
Resolved through the identity graph
- Member
- Eugene Nunez
- Member ID
- UHC-43631-44
- Date of birth
- 1969-01-28
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-418730
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-7684
- Coverage period
- 2025-01-01 to 2026-07-01
- Deductible
- $498.28 of $1,000.0050%
- Out-of-pocket maximum
- $811.31 of $3,000.0027%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 18 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $184.00 | $101.20 | — | — | DeniedCO27 |
| Totals | $184.00 | $101.20 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-752076
- 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-007084 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-24 is after coverage terminated on 2026-07-01. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 13 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 Center2026-07-24 09:19
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-06 00:55
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-08-06 12:31
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-752076.pdf9 pages
Itemised statement totalling $184.00 across 1 line.
- Er reported_report_PA-752076.pdf3 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 13:43Eligibility: Date of service 2026-07-24 is after coverage terminated on 2026-07-01.
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.