CLM-2026-021804
Valley Regional Medical Center, Emergency Medicine. Service 2026-03-13 at emergency room (POS 23). Received 2026-04-01.
Member
Resolved through the identity graph
- Member
- Beverly Bradley
- Member ID
- UHC-06774-15
- Date of birth
- 1977-11-02
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-428992
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group NULL
- Coverage period
- 2022-05-01 to present
- Deductible
- $84.93 of $500.0017%
- Out-of-pocket maximum
- $33.31 of $1,000.003%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 2408607978
- Network
- In network
- Rendering NPI
- 2408607978
- Location
- Austin, TX · TIN 89-0699789
- 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 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $1,885.00 | $1,036.75 | $150.00 | $886.75 | Paid |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $645.00 | $354.75 | $0.00 | $354.75 | Paid |
| 3 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1,2 | $1,252.00 | $688.60 | $0.00 | $688.60 | Paid |
| Totals | $3,782.00 | $2,080.10 | $150.00 | $1,930.10 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- Patient account
- PA-727806
- 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-023456 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-13: OPTIONS-PPO (PPO), effective 2022-05-01. | |
| Timely filing | Pass | Received 19 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 Valley Regional Medical Center (2408607978). | |
| 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 Regional Medical Center2026-03-13 10:14
Established patient presents with pneumonia, unspecified organism; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-727806.pdf6 pages
Itemised statement totalling $3782.00 across 3 lines.
- Er reported_report_PA-727806.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
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.