CLM-2026-021577
Summit Regional Medical Center, Emergency Medicine. Service 2026-06-29 at emergency room (POS 23). Received 2026-07-05.
Member
Resolved through the identity graph
- Member
- Teresa Thompson
- Member ID
- UHC-51683-44
- Date of birth
- 1988-10-23
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-424349
- Relationship
- Spouse, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-7617
- Coverage period
- 2025-03-01 to present
- Deductible
- $1,252.65 of $3,500.0036%
- Out-of-pocket maximum
- $3,113.42 of $10,500.0030%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 9 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 / 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 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $660.00 | $363.00 | $250.00 | $113.00 | Paid |
| 2 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,289.00 | $708.95 | $0.00 | $708.95 | Paid |
| Totals | $1,949.00 | $1,071.95 | $250.00 | $821.95 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- Patient account
- PA-373317
- 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-005362 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-29: OPTIONS-PPO (PPO), effective 2025-03-01. | |
| Timely filing | Pass | Received 6 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 Center2026-06-29 18:29
Established patient presents with pneumonia, unspecified organism; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-373317.pdf2 pages
Itemised statement totalling $1949.00 across 2 lines.
- Er reported_report_PA-373317.pdf3 pages
Emergency department record: triage acuity 3, chief complaint pneumonia, unspecified organism.
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-027981 | 2026-02-22 | Lakeside Medical Group | $394.00 | Approved |
| CLM-2026-017250 | 2025-12-29 | Sunrise Behavioral Health | $299.00 | Approved |
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.