CLM-2026-013479
Summit Regional Medical Center, Emergency Medicine. Service 2026-08-06 at emergency room (POS 23). Received 2026-08-08.
Member
Resolved through the identity graph
- Member
- Janet Weaver
- Member ID
- UHC-30144-81
- Date of birth
- 1995-02-05
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-429357
- Relationship
- Spouse, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-4822
- Coverage period
- 2025-02-01 to present
- Deductible
- $371.67 of $2,500.0015%
- Out-of-pocket maximum
- $1,121.87 of $7,500.0015%
- Copays
- office $30.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 1269847210
- Network
- In network
- Rendering NPI
- 1269847210
- Location
- Mesa, AZ · TIN 62-8021640
- Authorisation / referral
- none / REF784900
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 | $1,632.00 | $897.60 | $350.00 | $547.60 | Paid |
| 2 | 96374 rev 0260 | IV push, single drug | — | 1 | 2 | $249.00 | $136.95 | $0.00 | $136.95 | Paid |
| 3 | 71046 rev 0320 | Chest X-ray, two views | 25 | 1 | 1,2 | $178.00 | $97.90 | $0.00 | $97.90 | Paid |
| Totals | $2,059.00 | $1,132.45 | $350.00 | $782.45 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-798522
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-009403 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-06: CORE-HMO (HMO), effective 2025-02-01. | |
| Timely filing | Pass | Received 2 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 (1269847210). | |
| 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 Center2026-08-06 09:14
Patient seen for pneumonia, unspecified organism.
Attachments
Documents received with the claim
- Itemized billitemized_PA-798522.pdf6 pages
Itemised statement totalling $2059.00 across 3 lines.
- Er reported_report_PA-798522.pdf2 pages
Emergency department record: triage acuity 4, chief complaint pneumonia, unspecified organism.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001064 | 2026-04-25 | Meadow Primary Care Associates | $254.00 | 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.