CLM-2026-023596
Summit Community Hospital, Emergency Medicine. Service 2026-03-26 at emergency room (POS 23). Received 2026-04-28.
Member
Resolved through the identity graph
- Member
- Christina Dominguez
- Member ID
- UHC-80528-85
- Date of birth
- 1985-09-15
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-428785
- Relationship
- Child, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group NULL
- Coverage period
- 2023-11-01 to present
- Deductible
- $1,594.20 of $2,500.0064%
- Out-of-pocket maximum
- $4,642.32 of $10,000.0046%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 7504049959
- Network
- In network
- Rendering NPI
- 7504049959
- Location
- Austin, TX · TIN 97-1362073
- 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 | $2,571.00 | $1,414.05 | $250.00 | $1,164.05 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $225.00 | $123.75 | $0.00 | $123.75 | Paid |
| 3 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 2 | $1,635.00 | $899.25 | $0.00 | $899.25 | Paid |
| Totals | $4,431.00 | $2,437.05 | $250.00 | $2,187.05 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-371856
- 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-028207 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-26: OPTIONS-PPO (PPO), effective 2023-11-01. | |
| 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 | Pass | In-network provider Summit Community Hospital (7504049959). | |
| 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 Community Hospital2026-03-26 09:58
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-371856.pdf4 pages
Itemised statement totalling $4431.00 across 3 lines.
- Er reported_report_PA-371856.pdf3 pages
Emergency department record: triage acuity 2, chief complaint chest pain, unspecified.
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-2026-026158 | 2026-06-16 | Heritage Community Hospital | $2,417.00 | 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.