CLM-2026-020154
Summit Community Hospital, Emergency Medicine. Service 2025-12-21 at emergency room (POS 23). Received 2026-01-02.
Member
Resolved through the identity graph
- Member
- Brenda Watkins
- Member ID
- UHC-95987-55
- Date of birth
- 1970-04-22
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-410065
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-8303
- Coverage period
- 2022-08-01 to present
- Deductible
- $628.46 of $1,000.0063%
- Out-of-pocket maximum
- $1,760.59 of $4,000.0044%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 7504049959
- Network
- In network
- Rendering NPI
- 7504049959
- Location
- Austin, TX · TIN 97-1362073
- 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 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,240.00 | $682.00 | $250.00 | $432.00 | Paid |
| 2 | 96374 rev 0260 | IV push, single drug | — | 1 | 2 | $171.00 | $94.05 | $0.00 | $94.05 | Paid |
| Totals | $1,411.00 | $776.05 | $250.00 | $526.05 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- 3. J18.9 Pneumonia, unspecified organism
- Patient account
- PA-809495
- 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-000623 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2025-12-21: OPTIONS-PPO (PPO), effective 2022-08-01. | |
| Timely filing | Pass | Received 12 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 Community Hospital (7504049959). | |
| 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 Community Hospital2025-12-21 10:28
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-809495.pdf9 pages
Itemised statement totalling $1411.00 across 2 lines.
- Er reported_report_PA-809495.pdf5 pages
Emergency department record: triage acuity 3, chief complaint unspecified abdominal pain.
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
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.