CLM-2026-021597
Valley Community Hospital, Emergency Medicine. Service 2026-09-07 at emergency room (POS 23). Received 2026-10-06.
Member
Resolved through the identity graph
- Member
- Kelly Tucker
- Member ID
- UHC-00488-72
- Date of birth
- 1999-01-03
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-427335
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7727
- Coverage period
- 2022-11-01 to present
- Deductible
- $528.12 of $2,500.0021%
- Out-of-pocket maximum
- $1,699.06 of $7,500.0023%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 20 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 / REF623328
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 | $769.00 | $422.95 | — | — | Review |
| 2 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,562.00 | $859.10 | — | — | Review |
| 3 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $2,561.00 | $1,408.55 | — | — | Review |
| Totals | $4,892.00 | $2,690.60 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-888486
- 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-032154 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-07: NAVIGATE-HMO (HMO), effective 2022-11-01. | |
| Timely filing | Pass | Received 29 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 | Review | NET | Out-of-network emergency visit. Payable at the in-network level if the prudent-layperson standard is met; review the ED record. Out-of-network provider |
| 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 Hospital2026-09-07 14:48
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range. Patient presented to the nearest emergency department with acute symptoms; care could not safely be delayed to reach an in-network facility.
- SystemSystem: Claims system2026-10-06 02:54
Out-of-network emergency visit. Emergency services are payable at the in-network level when the prudent-layperson standard is met.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-10-06 13:00
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-888486.pdf3 pages
Itemised statement totalling $4892.00 across 3 lines.
- Er reported_report_PA-888486.pdf6 pages
Emergency department record: triage acuity 2, chief complaint chest pain, unspecified.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Provider network: Out-of-network emergency visit. Payable at the in-network level if the prudent-layperson standard is met; review the ED record.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005851 | 2026-09-10 | Unity Bone and Joint Center | $224.00 | Approved |
| CLM-2026-006629 | 2026-07-16 | Valley Primary Care Associates | $227.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Emergency: payable at in-network level.