CLM-2026-022955
Valley Community Hospital, Emergency Medicine. Service 2026-05-19 at emergency room (POS 23). Received 2026-06-21.
Member
Resolved through the identity graph
- Member
- Ruth Vazquez
- Member ID
- none on golden record
- Date of birth
- 2006-09-08
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-412978
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- MEDICARE-ADV-A MA group GRP-4819
- Coverage period
- 2024-03-01 to present
- Deductible
- $428.75 of $500.0086%
- Out-of-pocket maximum
- $235.30 of $2,000.0012%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 7 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 / 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 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $186.00 | $83.70 | — | — | PendedIDQ |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $204.00 | $91.80 | — | — | PendedIDQ |
| Totals | $390.00 | $175.50 | — | — | ||||||
- 1. S93.401A Sprain of unspecified ligament of right ankle, initial encounterprincipal
- Patient account
- PA-291822
- Frequency code
- 1 (original)
- Accident
- Yes
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-001210; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-05-19: MEDICARE-ADV-A (MA), effective 2024-03-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 33 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Hospital2026-05-19 10:53
Follow-up for sprain of unspecified ligament of right ankle, initial encounter. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-291822.pdf2 pages
Itemised statement totalling $390.00 across 2 lines.
- Er reported_report_PA-291822.pdf6 pages
Emergency department record: triage acuity 2, chief complaint sprain of unspecified ligament of right ankle, initial encounter.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-001210; payment withheld until the identity is confirmed. Eligibility: Active on 2026-05-19: MEDICARE-ADV-A (MA), effective 2024-03-01. Coverage found by name and date of birth because the claim carried no usable member ID. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
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
Clean claim, priced at contract rate.