CLM-2026-020985
Valley Community Hospital, Emergency Medicine. Service 2026-08-18 at emergency room (POS 23). Received 2026-09-05.
Member
Resolved through the identity graph
- Member
- Mason Brown
- Member ID
- UHC-44719-67
- Date of birth
- 2006-09-20
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-408205
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8751
- Coverage period
- 2021-08-01 to present
- Deductible
- $286.81 of $500.0057%
- Out-of-pocket maximum
- $442.97 of $1,500.0030%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 3406943738
- Network
- Out of network
- Rendering NPI
- 3406943738
- Location
- Austin, TX · TIN 13-2256808
- 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 | $1,780.00 | $801.00 | $250.00 | $551.00 | Paid |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1,2 | $712.00 | $320.40 | $0.00 | $320.40 | Paid |
| 3 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 2 | $2,739.00 | $1,232.55 | $0.00 | $1,232.55 | Paid |
| Totals | $5,231.00 | $2,353.95 | $250.00 | $2,103.95 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. J18.9 Pneumonia, unspecified organism
- 3. R55 Syncope and collapse
- Patient account
- PA-665856
- 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
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-016155 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-08-18: NULL (PPO), effective 2021-08-01. | |
| Timely filing | Pass | Received 18 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Valley Community Hospital2026-08-18 14:39
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-665856.pdf2 pages
Itemised statement totalling $5231.00 across 3 lines.
- Er reported_report_PA-665856.pdf5 pages
Emergency department record: triage acuity 2, chief complaint chest pain, unspecified.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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.