CLM-2026-012185
Valley Regional Medical Center, Emergency Medicine. Service 2026-06-10 at emergency room (POS 23). Received 2026-06-16.
Member
Resolved through the identity graph
- Member
- Chris Washington
- Member ID
- UHC-95770-57
- Date of birth
- 1996-03-01
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-419767
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-5847
- Coverage period
- 2024-02-01 to 2026-08-21
- Deductible
- $653.77 of $1,000.0065%
- Out-of-pocket maximum
- $898.50 of $2,000.0045%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 5 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 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $252.00 | $138.60 | $138.60 | $0.00 | Paid |
| Totals | $252.00 | $138.60 | $138.60 | $0.00 | ||||||
- 1. R55 Syncope and collapseprincipal
- 2. J18.9 Pneumonia, unspecified organism
- Patient account
- PA-754042
- Frequency code
- 1 (original)
- Accident
- Yes
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-035158 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-06-10: NULL (PPO), effective 2024-02-01, terms 2026-08-21. | |
| Timely filing | Pass | Received 6 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 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 Center2026-06-10 18:11
Follow-up for syncope and collapse. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-754042.pdf7 pages
Itemised statement totalling $252.00 across 1 line.
- Er reported_report_PA-754042.pdf3 pages
Emergency department record: triage acuity 3, chief complaint syncope and collapse.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-003241 | 2026-06-02 | Cornerstone Family Practice | $290.00 | 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.