Claims workbench/CLM-2026-023742

Institutional claim · UB-04 · EDI 837I

CLM-2026-023742

Summit Regional Medical Center, Emergency Medicine. Service 2026-09-16 at emergency room (POS 23). Received 2026-10-12.

Needs review

Billed

$2,954.00

2 lines

Allowed

$1,624.70

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Review

CO97

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Adam Vega
Member ID: UHC-59055-13
Date of birth: 1992-02-01
Identity: Verified6 records, confidence 0.99
Claim record: CLMCLM-425771
Relationship: Self, Chandler, AZ

Coverage and accumulators

Found by member ID

Plan: OPTIONS-PPO PPO group GRP-3911
Coverage period: 2024-03-01 to present
Deductible: $158.59 of $2,500.006%
Out-of-pocket maximum: $1,385.71 of $10,000.0014%
Copays: office $40.00, specialist $60.00, emergency $250.00
Physical therapy visits: 3 of 20 used

Provider

Billing and rendering

Billing provider: Summit Regional Medical Center
Emergency Medicine · taxonomy 207P00000X
NPI: 1269847210
Network: In network
Rendering NPI: 1269847210
Location: Mesa, AZ · TIN 62-8021640
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	59	1	1	$198.00	$108.90	—	—	Review
2	99285 rev 0450	Emergency department visit, high severity with threat to life	59	1	2	$2,756.00	$1,515.80	—	—	Review
Totals						$2,954.00	$1,624.70	—	—

Diagnoses (ICD-10-CM)

1. S93.401A Sprain of unspecified ligament of right ankle, initial encounterprincipal
2. R07.9 Chest pain, unspecified

Claim header

Patient account: PA-236765
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-027921 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-09-16: OPTIONS-PPO (PPO), effective 2024-03-01.
Timely filing	Pass		Received 26 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 Regional Medical Center (1269847210).
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Review	CO97	Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated
Benefit limits	Pass		No limited benefit on this claim.
Completeness	Pass		Required documentation present.
High-dollar review	Pass		Within the auto-adjudication ceiling.

Evaluated 2026-10-21 13:43 under policy version 1. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Summit Regional Medical Center2026-09-16 12:06
Patient seen for sprain of unspecified ligament of right ankle, initial encounter. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
SystemSystem: Claims system2026-10-12 04:50
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
AdministrativeExaminer: R. Patel (Claims Examiner II)2026-10-12 10:06
Escalated to nurse reviewer for clinical opinion.

Attachments

Documents received with the claim

Itemized billitemized_PA-236765.pdf3 pages
Itemised statement totalling $2954.00 across 2 lines.
Medical recordrecords_PA-236765.pdf5 pages
Operative note describing procedures at two distinct anatomical sites.
Er reported_report_PA-236765.pdf3 pages
Emergency department record: triage acuity 3, chief complaint sprain of unspecified ligament of right ankle, initial encounter.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-005712	2026-08-06	Desert Clinical Laboratories	$194.00	Denied
CLM-2026-005711	2026-08-06	Desert Clinical Laboratories	$194.00	Approved
CLM-2026-000009	2026-07-27	Lakeside Physical Therapy	$266.00	Approved
CLM-2026-017511	2026-05-08	Mesa Medical Group	$223.00	Approved
CLM-2026-026554	2026-04-12	Sunrise Digestive Health Center	$4,959.00	Needs review

AI recommendation

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

The rules engine left this claim for review. The AI adjudicator can read the evidence pack (lines, notes, attachments, coverage, history) and recommend an outcome with citations.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

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: Unbundling supported

Modifier 59 supported: distinct anatomical site documented.

Review queue Member identity