CLM-2026-011206
Valley Regional Medical Center, Emergency Medicine. Service 2025-10-28 at emergency room (POS 23). Received 2026-05-05.
Member
Resolved through the identity graph
- Member
- Jeremy Patel
- Member ID
- UHC-07309-11
- Date of birth
- 1990-06-20
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-407483
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-5130
- Coverage period
- 2024-11-01 to present
- Deductible
- $1,765.53 of $3,500.0050%
- Out-of-pocket maximum
- $6,333.87 of $14,000.0045%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 2408607978
- Network
- In network
- Rendering NPI
- 2408607978
- Location
- Austin, TX · TIN 89-0699789
- 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 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,129.00 | $620.95 | — | — | DeniedCO29 |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | 25 | 1 | 1,2 | $635.00 | $349.25 | — | — | DeniedCO29 |
| 3 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $178.00 | $97.90 | — | — | DeniedCO29 |
| Totals | $1,942.00 | $1,068.10 | — | — | ||||||
- 1. R55 Syncope and collapseprincipal
- 2. R10.9 Unspecified abdominal pain
- 3. R07.9 Chest pain, unspecified
- Patient account
- PA-370118
- 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-029206 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-10-28: MEDICARE-ADV-A (MA), effective 2024-11-01. | |
| Timely filing | Fail | CO29 | Received 189 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 Valley Regional Medical Center (2408607978). | |
| 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 Regional Medical Center2025-10-28 17:27
Patient seen for syncope and collapse.
- SystemSystem: Claims system2026-05-05 03:48
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
- Itemized billitemized_PA-370118.pdf8 pages
Itemised statement totalling $1942.00 across 3 lines.
- Er reported_report_PA-370118.pdf3 pages
Emergency department record: triage acuity 4, chief complaint syncope and collapse.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 189 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033520 | 2026-04-17 | Lakeside Imaging Center | $1,966.00 | 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.