Claims workbench/CLM-2026-022081
Institutional claim · UB-04 · Paper

CLM-2026-022081

Summit Regional Medical Center, Emergency Medicine. Service 2026-01-25 at emergency room (POS 23). Received 2026-02-09.

Approved
Billed
$190.00
1 line
Allowed
$104.50
contract rate applied
Plan pays
$0.00
approved
Member owes
$104.50
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Betty Garrett
Member ID
UHC-03172-62
Date of birth
1995-10-13
Identity
Verified2 records, confidence 0.99
Claim record
CLMCLM-431772
Relationship
Spouse, Austin, TX

Coverage and accumulators

Found by member ID

Plan
N/A PPO group UNKNOWN
Coverage period
2024-07-01 to present
Deductible
$364.95 of $2,500.0015%
Out-of-pocket maximum
$572.71 of $10,000.006%
Copays
office $40.00, specialist $50.00, emergency $350.00
Physical therapy visits
19 of 20 used

Provider

Billing and rendering

Billing provider
Summit Regional Medical Center
Emergency Medicine · taxonomy 207P00000X
NPI
7959926214
Network
In network
Rendering NPI
7959926214
Location
Mesa, AZ · TIN 13-8570749
Authorisation / referral
none / none

Service lines

UB-04: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
196374
rev 0260
IV push, single drug—11$190.00$104.50$104.50$0.00Paid
Totals$190.00$104.50$104.50$0.00
Diagnoses (ICD-10-CM)
  • 1. R07.9 Chest pain, unspecifiedprincipal
  • 2. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
Claim header
Patient account
PA-410580
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

CheckResultCodeDetail
Member identityPassAttached to MBR-011655 (verified, link confidence 0.99).
EligibilityPassActive on 2026-01-25: N/A (PPO), effective 2024-07-01.
Timely filingPassReceived 15 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Summit Regional Medical Center (7959926214).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Summit Regional Medical Center2026-01-25 16:54

    Patient seen for chest pain, unspecified.

Attachments

Documents received with the claim

  • Itemized billitemized_PA-410580.pdf5 pages

    Itemised statement totalling $190.00 across 1 line.

  • Er reported_report_PA-410580.pdf4 pages

    Emergency department record: triage acuity 2, chief complaint chest pain, unspecified.

Explanation of benefits

What the member will see

Amount billed
$190.00
Plan discount
$85.50
contracted rate
Plan paid
$0.00
You may owe
$104.50
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-22 12:44
    Clean claim.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

Clean claim: the rules engine approved it, so no AI review was needed.

Examiner decision

Approved by Claims rules engine; an examiner may still override

Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queueMember identity