Claims workbench/CLM-2026-018519

Institutional claim · UB-04 · EDI 837I

CLM-2026-018519

Riverside Community Hospital, Emergency Medicine. Service 2026-09-25 at emergency room (POS 23). Received 2026-10-14.

Approved

Billed

$203.00

1 line

Allowed

$111.65

contract rate applied

Plan pays

$0.00

approved

Member owes

$111.65

copay / deductible / 10% coinsurance

Rules engine

Clean

no reason codes

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Steven Gilbert
Member ID: UHC-22739-27
Date of birth: 1963-10-24
Identity: Verified5 records, confidence 0.96
Claim record: CLMCLM-409154
Relationship: Self, Tampa, FL

Coverage and accumulators

Found by member ID

Plan: NAVIGATE-HMO HMO group GRP-5736
Coverage period: 2023-05-01 to present
Deductible: $756.44 of $1,000.0076%
Out-of-pocket maximum: $547.57 of $2,000.0027%
Copays: office $30.00, specialist $60.00, emergency $250.00
Physical therapy visits: 18 of 20 used

Provider

Billing and rendering

Billing provider: Riverside Community Hospital
Emergency Medicine · taxonomy 207P00000X
NPI: 1928747868
Network: In network
Rendering NPI: 1928747868
Location: Mesa, AZ · TIN 30-6800456
Authorisation / referral: none / REF279113

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	96374 rev 0260	IV push, single drug	—	1	1	$203.00	$111.65	$111.65	$0.00	Paid
Totals						$203.00	$111.65	$111.65	$0.00

Diagnoses (ICD-10-CM)

1. S93.401A Sprain of unspecified ligament of right ankle, initial encounterprincipal
2. R10.9 Unspecified abdominal pain
3. J18.9 Pneumonia, unspecified organism

Claim header

Patient account: PA-926295
Frequency code: 1 (original)
Accident: Yes
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 0 needing attention

Check	Result	Detail
Member identity	Pass	Attached to MBR-002957 (verified, link confidence 0.96).
Eligibility	Pass	Active on 2026-09-25: NAVIGATE-HMO (HMO), effective 2023-05-01.
Timely filing	Pass	Received 19 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 Riverside Community Hospital (1928747868).
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. Clean claim: approved and priced automatically.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Riverside Community Hospital2026-09-25 14:55
Established patient presents with sprain of unspecified ligament of right ankle, initial encounter; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

Itemized billitemized_PA-926295.pdf6 pages
Itemised statement totalling $203.00 across 1 line.
Er reported_report_PA-926295.pdf2 pages
Emergency department record: triage acuity 4, chief complaint sprain of unspecified ligament of right ankle, initial encounter.

Explanation of benefits

What the member will see

Amount billed

$203.00

Plan discount

$91.35

contracted rate

Plan paid

$0.00

You may owe

$111.65

copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

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

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-022432	2026-09-06	Lakeside Behavioral Health	$439.00	Denied
CLM-2026-002569	2026-03-25	Unity Community Hospital	$2,227.00	Approved
CLM-2026-019699	2025-12-30	Valley Medical Group	$2,901.00	Needs review

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

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: Clean

Clean claim, priced at contract rate.

Review queue Member identity