Claims workbench/CLM-2026-017496
Institutional claim · UB-04 · EDI 837I

CLM-2026-017496

Unity Community Hospital, Emergency Medicine. Service 2026-09-12 at emergency room (POS 23). Received 2026-09-15.

Pended
Billed
$2,208.00
2 lines
Allowed
$1,214.40
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
N30
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Emma Ruiz
Member ID
none on golden record
Date of birth
1990-04-02
Identity
Verified4 records, confidence 0.98
Claim record
CLMCLM-419563
Relationship
Self, Atlanta, GA

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Unity Community Hospital
Emergency Medicine · taxonomy 207P00000X
NPI
5583357806
Network
In network
Rendering NPI
5583357806
Location
Tempe, AZ · TIN 68-0325602
Authorisation / referral
none / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199285
rev 0450
Emergency department visit, high severity with threat to life—11$2,087.00$1,147.85——PendedN30
271046
rev 0320
Chest X-ray, two views—11$121.00$66.55——PendedN30
Totals$2,208.00$1,214.40——
Diagnoses (ICD-10-CM)
  • 1. J18.9 Pneumonia, unspecified organismprincipal
Claim header
Patient account
PA-223499
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

CheckResultCodeDetail
Member identityPassAttached to MBR-022435 (verified, link confidence 0.98).
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 3 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Unity Community Hospital (5583357806).
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. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Unity Community Hospital2026-09-12 10:28

    Patient seen for pneumonia, unspecified organism.

Attachments

Documents received with the claim

  • Itemized billitemized_PA-223499.pdf8 pages

    Itemised statement totalling $2208.00 across 2 lines.

  • Er reported_report_PA-223499.pdf2 pages

    Emergency department record: triage acuity 4, chief complaint pneumonia, unspecified organism.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-21 13:43
    Eligibility: No coverage segment found for the member ID on this claim.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

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

A hard rule decided this claim; the AI is advisory here.

Examiner decision

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

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