Claims workbench/CLM-2026-016859
Institutional claim · UB-04 · Provider portal

CLM-2026-016859

Meadow Regional Medical Center, Emergency Medicine. Service 2026-05-05 at emergency room (POS 23). Received 2026-06-06.

Approved
Billed
$205.00
1 line
Allowed
$112.75
contract rate applied
Plan pays
$0.00
approved
Member owes
$112.75
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Diane Henderson
Member ID
UHC-09074-03
Date of birth
1946-12-20
Identity
Verified3 records, confidence 0.99
Claim record
CLMCLM-410763
Relationship
Self, Phoenix, AZ

Coverage and accumulators

Found by member ID

Plan
CHOICE-PLUS-PPO PPO group GRP-4255
Coverage period
2022-07-01 to present
Deductible
$424.75 of $1,500.0028%
Out-of-pocket maximum
$873.14 of $4,500.0019%
Copays
office $20.00, specialist $40.00, emergency $250.00
Physical therapy visits
9 of 20 used

Provider

Billing and rendering

Billing provider
Meadow Regional Medical Center
Emergency Medicine · taxonomy 207P00000X
NPI
1905050427
Network
In network
Rendering NPI
1905050427
Location
Dallas, TX · TIN 71-2312931
Authorisation / referral
none / none

Service lines

UB-04: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
196374
rev 0260
IV push, single drug—11$205.00$112.75$112.75$0.00Paid
Totals$205.00$112.75$112.75$0.00
Diagnoses (ICD-10-CM)
  • 1. R07.9 Chest pain, unspecifiedprincipal
Claim header
Patient account
PA-312100
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 0 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-018374 (verified, link confidence 0.99).
EligibilityPassActive on 2026-05-05: NULL (PPO), effective 2022-07-01.
Timely filingPassReceived 32 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Meadow Regional Medical Center (1905050427).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Meadow Regional Medical Center2026-05-05 14:31

    Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

  • Itemized billitemized_PA-312100.pdf9 pages

    Itemised statement totalling $205.00 across 1 line.

  • Er reported_report_PA-312100.pdf6 pages

    Emergency department record: triage acuity 4, chief complaint chest pain, unspecified.

Explanation of benefits

What the member will see

Amount billed
$205.00
Plan discount
$92.25
contracted rate
Plan paid
$0.00
You may owe
$112.75
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-21 13:43
    Clean claim.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

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

Clean claim: the rules engine approved it, so no AI review was needed.

Examiner decision

Approved by Claims rules engine; an examiner may still override

Outcome
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: Clean

Clean claim, priced at contract rate.

Review queueMember identity