CLM-2026-016584
Summit Regional Medical Center, Emergency Medicine. Service 2025-11-30 at emergency room (POS 23). Received 2026-01-10.
Member
Resolved through the identity graph
- Member
- Jose Kennedy
- Member ID
- UHC-68721-38
- Date of birth
- 1954-07-19
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-420486
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-0383
- Coverage period
- 2024-05-01 to present
- Deductible
- $420.50 of $1,000.0042%
- Out-of-pocket maximum
- $1,288.00 of $4,000.0032%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 7959926214
- Network
- In network
- Rendering NPI
- 7959926214
- Location
- Mesa, AZ · TIN 13-8570749
- 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 | $1,093.00 | $601.15 | $250.00 | $351.15 | Paid |
| 2 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $215.00 | $118.25 | $0.00 | $118.25 | Paid |
| 3 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $2,110.00 | $1,160.50 | $0.00 | $1,160.50 | Paid |
| Totals | $3,418.00 | $1,879.90 | $250.00 | $1,629.90 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-138950
- Frequency code
- 1 (original)
- Accident
- No
- 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-003034 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-11-30: MEDICARE-ADV-B (MA), effective 2024-05-01. | |
| Timely filing | Pass | Received 41 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 (7959926214). | |
| 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 Center2025-11-30 09:43
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-138950.pdf5 pages
Itemised statement totalling $3418.00 across 3 lines.
- Er reported_report_PA-138950.pdf3 pages
Emergency department record: triage acuity 2, chief complaint chest pain, unspecified.
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-2026-021387 | 2026-05-08 | Meadow Physical Therapy | $158.00 | Denied |
| CLM-2026-016585 | 2025-11-30 | Summit Regional Medical Center | $3,418.00 | Denied |
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.