Claims workbench/CLM-2026-013731
Institutional claim · UB-04 · EDI 837I

CLM-2026-013731

Valley Regional Medical Center, Emergency Medicine. Service 2026-07-06 at emergency room (POS 23). Received 2026-07-08.

Pended
Billed
$3,437.00
2 lines
Allowed
$1,890.35
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
N30
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Mei Wells
Member ID
none on golden record
Date of birth
1943-04-10
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-412948
Relationship
Self, Sacramento, CA

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Valley Regional Medical Center
Emergency 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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199284
rev 0450
Emergency department visit, high severity—11$1,579.00$868.45——PendedN30
299285
rev 0450
Emergency department visit, high severity with threat to life—12$1,858.00$1,021.90——PendedN30
Totals$3,437.00$1,890.35——
Diagnoses (ICD-10-CM)
  • 1. R10.9 Unspecified abdominal painprincipal
  • 2. R07.9 Chest pain, unspecified
Claim header
Patient account
PA-629841
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

CheckResultCodeDetail
Member identityPassAttached to MBR-037768 (provisional, link confidence 1.00).
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 2 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Valley Regional Medical Center (2408607978).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Valley Regional Medical Center2026-07-06 13:25

    Patient seen for unspecified abdominal pain.

Attachments

Documents received with the claim

  • Itemized billitemized_PA-629841.pdf3 pages

    Itemised statement totalling $3437.00 across 2 lines.

  • Er reported_report_PA-629841.pdf2 pages

    Emergency department record: triage acuity 3, chief complaint unspecified abdominal pain.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-22 12:44
    Eligibility: No coverage segment found for the member ID on this claim.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queueMember identity