CLM-2026-015410
Summit Regional Medical Center, Emergency Medicine. Service 2026-08-16 at emergency room (POS 23). Received 2026-08-23.
Member
Resolved through the identity graph
- Member
- George Stephens
- Member ID
- UHC-58119-10
- Date of birth
- 1970-12-10
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-403114
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-9233
- Coverage period
- 2021-02-01 to present
- Deductible
- $1,234.93 of $1,500.0082%
- Out-of-pocket maximum
- $18.99 of $3,000.001%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 3 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 | $740.00 | $407.00 | $350.00 | $57.00 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | 25 | 1 | 1 | $132.00 | $72.60 | $0.00 | $72.60 | Paid |
| 3 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $2,784.00 | $1,531.20 | $0.00 | $1,531.20 | Paid |
| Totals | $3,656.00 | $2,010.80 | $350.00 | $1,660.80 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- Patient account
- PA-220742
- 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-034990 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-16: MEDICARE-ADV-A (MA), effective 2021-02-01. | |
| Timely filing | Pass | Received 7 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 (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 Center2026-08-16 10:44
Established patient presents with pneumonia, unspecified organism; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-220742.pdf4 pages
Itemised statement totalling $3656.00 across 3 lines.
- Er reported_report_PA-220742.pdf4 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 engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029548 | 2026-05-03 | Lakeside Bone and Joint Center | $1,904.00 | 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.