Claims workbench/CLM-2026-019943
Institutional claim · UB-04 · EDI 837I

CLM-2026-019943

Summit Regional Medical Center, Emergency Medicine. Service 2026-05-27 at emergency room (POS 23). Received 2026-06-04.

PendedIdentity on hold: CASE-004098
Billed
$1,534.00
2 lines
Allowed
$843.70
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
IDQ, N30
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Carolyn Morales
Member ID
none on golden record
Date of birth
—
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-420168
Relationship
Self, Miami, FL

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Summit Regional Medical Center
Emergency Medicine · taxonomy 207P00000X
NPI
3973431752
Network
In network
Rendering NPI
3973431752
Location
Nashville, TN · TIN 74-3643207
Authorisation / referral
none / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199284
rev 0450
Emergency department visit, high severity—11$1,387.00$762.85——PendedIDQ
271046
rev 0320
Chest X-ray, two views—12$147.00$80.85——PendedIDQ
Totals$1,534.00$843.70——
Diagnoses (ICD-10-CM)
  • 1. J18.9 Pneumonia, unspecified organismprincipal
Claim header
Patient account
PA-867485
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

CheckResultCodeDetail
Member identityFailIDQMember record is in open steward case CASE-004098; payment withheld until the identity is confirmed.
Member identity under steward review
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 8 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Summit Regional Medical Center (3973431752).
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: Summit Regional Medical Center2026-05-27 11:30

    Follow-up for pneumonia, unspecified organism. Plan discussed, medications reconciled.

Attachments

Documents received with the claim

  • Itemized billitemized_PA-867485.pdf3 pages

    Itemised statement totalling $1534.00 across 2 lines.

  • Er reported_report_PA-867485.pdf6 pages

    Emergency department record: triage acuity 2, chief complaint pneumonia, unspecified organism.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-21 13:43
    Member identity: Member record is in open steward case CASE-004098; payment withheld until the identity is confirmed. 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