CLM-2026-014992
Valley Community Hospital, Emergency Medicine. Service 2026-10-03 at emergency room (POS 23). Received 2026-10-16.
Member
Resolved through the identity graph
- Member
- Patricia Hayes
- Member ID
- UHC-59679-50
- Date of birth
- 2000-07-03
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-407432
- Relationship
- Spouse, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-1026
- Coverage period
- 2022-09-01 to present
- Deductible
- $144.96 of $500.0029%
- Out-of-pocket maximum
- $612.79 of $2,000.0031%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 3406943738
- Network
- Out of network
- Rendering NPI
- 3406943738
- Location
- Austin, TX · TIN 13-2256808
- 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 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $2,991.00 | $1,345.95 | $350.00 | $995.95 | Paid |
| 2 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $186.00 | $83.70 | $0.00 | $83.70 | Paid |
| 3 | 99284 rev 0450 | Emergency department visit, high severity | 25 | 1 | 1 | $1,691.00 | $760.95 | $0.00 | $760.95 | Paid |
| Totals | $4,868.00 | $2,190.60 | $350.00 | $1,840.60 | ||||||
- 1. S93.401A Sprain of unspecified ligament of right ankle, initial encounterprincipal
- Patient account
- PA-688273
- 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-012995 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-10-03: MEDICARE-ADV-A (MA), effective 2022-09-01. | |
| Timely filing | Pass | Received 13 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Community Hospital2026-10-03 17:41
Patient seen for sprain of unspecified ligament of right ankle, initial encounter.
Attachments
Documents received with the claim
- Itemized billitemized_PA-688273.pdf9 pages
Itemised statement totalling $4868.00 across 3 lines.
- Er reported_report_PA-688273.pdf5 pages
Emergency department record: triage acuity 4, chief complaint sprain of unspecified ligament of right ankle, initial encounter.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
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.