CLM-2026-014088
Summit Regional Medical Center, Emergency Medicine. Service 2026-02-09 at emergency room (POS 23). Received 2026-05-18.
Member
Resolved through the identity graph
- Member
- Shirley Fisher
- Member ID
- UHC-31923-24
- Date of birth
- 1945-07-04
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-429967
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7831
- Coverage period
- 2022-12-01 to present
- Deductible
- $53.04 of $2,500.002%
- Out-of-pocket maximum
- $1,417.76 of $10,000.0014%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 0 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 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $978.00 | $537.90 | — | — | DeniedCO29 |
| 2 | 99284 rev 0450 | Emergency department visit, high severity | 25 | 1 | 1 | $1,243.00 | $683.65 | — | — | DeniedCO29 |
| Totals | $2,221.00 | $1,221.55 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-845438
- Frequency code
- 1 (original)
- Accident
- Yes
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-031224 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-09: CHOICE-PLUS-PPO (PPO), effective 2022-12-01. | |
| Timely filing | Fail | CO29 | Received 98 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 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 Center2026-02-09 13:13
Patient seen for chest pain, unspecified.
- SystemSystem: Claims system2026-05-18 00:44
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-845438.pdf6 pages
Itemised statement totalling $2221.00 across 2 lines.
- Er reported_report_PA-845438.pdf6 pages
Emergency department record: triage acuity 4, chief complaint chest pain, unspecified.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 98 days after the last date of service (limit 90).
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
Received after the timely-filing limit.