CLM-2026-021118
Summit Regional Medical Center, Emergency Medicine. Service 2025-12-26 at emergency room (POS 23). Received 2026-01-23.
Member
Resolved through the identity graph
- Member
- Ahmed Singh
- Member ID
- UHC-12787-60
- Date of birth
- 1979-01-17
- Identity
- Verified3 records, confidence 0.93
- Claim record
- CLMCLM-416940
- Relationship
- Spouse, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-6279
- Coverage period
- 2022-03-01 to present
- Deductible
- $2,261.78 of $3,500.0065%
- Out-of-pocket maximum
- $354.07 of $10,500.003%
- Copays
- office $30.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 3973431752
- Network
- In network
- Rendering NPI
- 3973431752
- Location
- Nashville, TN · TIN 74-3643207
- Authorisation / referral
- none / REF775781
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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $165.00 | $90.75 | $90.75 | $0.00 | Paid |
| 2 | 96374 rev 0260 | IV push, single drug | 25 | 1 | 1 | $203.00 | $111.65 | $0.00 | $111.65 | Paid |
| 3 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,277.00 | $702.35 | $0.00 | $702.35 | Paid |
| Totals | $1,645.00 | $904.75 | $90.75 | $814.00 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. J18.9 Pneumonia, unspecified organism
- Patient account
- PA-631910
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-006910 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2025-12-26: NAVIGATE-HMO (HMO), effective 2022-03-01. | |
| Timely filing | Pass | Received 28 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 Regional Medical Center (3973431752). | |
| 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 Regional Medical Center2025-12-26 09:05
Patient seen for unspecified abdominal pain.
Attachments
Documents received with the claim
- Itemized billitemized_PA-631910.pdf5 pages
Itemised statement totalling $1645.00 across 3 lines.
- Er reported_report_PA-631910.pdf3 pages
Emergency department record: triage acuity 2, 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 engineApproved2026-10-21 13:43Clean 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.