Claims workbench/CLM-2026-015437

Institutional claim · UB-04 · Paper

CLM-2026-015437

Valley Community Hospital, Emergency Medicine. Service 2026-08-19 at emergency room (POS 23). Received 2026-10-03.

Needs reviewReplacement of CLM-2026-015436Out of network

Billed

$1,059.00

2 lines

Allowed

$476.55

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Review

REPL

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Joshua Harper
Member ID: UHC-85497-41
Date of birth: 1971-08-11
Identity: Verified3 records, confidence 0.99
Claim record: CLMCLM-421911
Relationship: Self, Los Angeles, CA

Coverage and accumulators

Found by member ID

Plan: CHOICE-PLUS-PPO PPO group GRP-4133
Coverage period: 2023-07-01 to present
Deductible: $113.92 of $500.0023%
Out-of-pocket maximum: $565.57 of $2,000.0028%
Copays: office $20.00, specialist $40.00, emergency $250.00
Physical therapy visits: 8 of 20 used

Provider

Billing and rendering

Billing provider: Valley Community Hospital
Emergency 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	71046 rev 0320	Chest X-ray, two views	—	1	1	$211.00	$94.95	—	—	Review
2	99283 rev 0450	Emergency department visit, moderate severity	—	1	2	$848.00	$381.60	—	—	Review
Totals						$1,059.00	$476.55	—	—

Diagnoses (ICD-10-CM)

1. J18.9 Pneumonia, unspecified organismprincipal
2. S93.401A Sprain of unspecified ligament of right ankle, initial encounter

Claim header

Patient account: PA-504421
Frequency code: 7 (replacement)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 12 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-014048 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-08-19: N/A (PPO), effective 2023-07-01.
Timely filing	Pass		Received 45 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Replacement claim	Review	REPL	Frequency code 7 replaces CLM-2026-015436; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission
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.

Evaluated 2026-10-21 13:43 under policy version 1. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Valley Community Hospital2026-08-19 15:46
Established patient presents with pneumonia, unspecified organism; symptoms reviewed and vitals within expected range. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
SystemSystem: Claims system2026-10-03 02:03
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.

Attachments

Documents received with the claim

Itemized billitemized_PA-504421.pdf6 pages
Itemised statement totalling $1059.00 across 2 lines.
Er reported_report_PA-504421.pdf6 pages
Emergency department record: triage acuity 2, chief complaint pneumonia, unspecified organism.
Corrected claimcorrected_CLM-2026-015436.pdf1 page
Provider cover letter requesting replacement of CLM-2026-015436.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Replacement claim: Frequency code 7 replaces CLM-2026-015436; the original must be voided when this adjudicates. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-015436	2026-08-19	Valley Community Hospital	$1,059.00	Approved
CLM-2026-018539	2026-01-18	Unity Digestive Health Center	$2,206.00	Approved

AI recommendation

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

The rules engine left this claim for review. The AI adjudicator can read the evidence pack (lines, notes, attachments, coverage, history) and recommend an outcome with citations.

Examiner decision

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

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

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: Replacement

Replacement claim supersedes the original.

Review queue Member identity