CLM-2026-023678
Summit Community Hospital, Emergency Medicine. Service 2025-12-13 at emergency room (POS 23). Received 2026-01-18.
Member
Resolved through the identity graph
- Member
- Jeremy Hunter
- Member ID
- UHC-17184-54
- Date of birth
- 1942-06-27
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-419692
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-4380
- Coverage period
- 2022-07-01 to present
- Deductible
- $2,201.71 of $3,500.0063%
- Out-of-pocket maximum
- $2,585.99 of $14,000.0018%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 7 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 | $2,131.00 | $1,172.05 | $150.00 | $1,022.05 | Paid |
| 2 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $186.00 | $102.30 | $0.00 | $102.30 | Paid |
| Totals | $2,317.00 | $1,274.35 | $150.00 | $1,124.35 | ||||||
- 1. R55 Syncope and collapseprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-405900
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-005545 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-13: MEDICARE-ADV-A (MA), effective 2022-07-01. | |
| Timely filing | Pass | Received 36 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 Hospital2025-12-13 10:03
Patient seen for syncope and collapse. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-01-18 05:34
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-405900.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
- Itemized billitemized_PA-405900.pdf9 pages
Itemised statement totalling $2317.00 across 2 lines.
- Er reported_report_PA-405900.pdf2 pages
Emergency department record: triage acuity 3, chief complaint syncope and collapse.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean 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
Authorisation must be confirmed with UM before payment.