CLM-2026-023750
Valley Regional Medical Center, Emergency Medicine. Service 2025-12-27 at emergency room (POS 23). Received 2026-01-06.
Member
Resolved through the identity graph
- Member
- Matthew Ward
- Member ID
- UHC-15822-54
- Date of birth
- 1944-03-10
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-424181
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5568
- Coverage period
- 2025-08-01 to present
- Deductible
- $1,819.64 of $2,500.0073%
- Out-of-pocket maximum
- $1,901.80 of $10,000.0019%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 2408607978
- Network
- In network
- Rendering NPI
- 2408607978
- Location
- Austin, TX · TIN 89-0699789
- 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 | 71046 rev 0320 | Chest X-ray, two views | 59 | 1 | 1 | $137.00 | $75.35 | — | — | Review |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | 59 | 1 | 2 | $865.00 | $475.75 | — | — | Review |
| 3 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,041.00 | $572.55 | — | — | Review |
| Totals | $2,043.00 | $1,123.65 | — | — | ||||||
- 1. R55 Syncope and collapseprincipal
- Patient account
- PA-755202
- 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-001925 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-27: CHOICE-PLUS-PPO (PPO), effective 2025-08-01. | |
| Timely filing | Pass | Received 10 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 Valley Regional Medical Center (2408607978). | |
| 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Valley Regional Medical Center2025-12-27 15:10
Follow-up for syncope and collapse. Plan discussed, medications reconciled. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-01-06 05:09
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-01-06 16:46
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-755202.pdf7 pages
Itemised statement totalling $2043.00 across 3 lines.
- Medical recordrecords_PA-755202.pdf13 pages
Operative note describes a single procedure at one site; no separate session.
- Er reported_report_PA-755202.pdf3 pages
Emergency department record: triage acuity 2, chief complaint syncope and collapse.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
- AI recommendationDenied2026-10-21 14:15The claim includes a chest X-ray (71046) and an emergency department visit (99283) with a modifier 59, which are normally bundled services. The clinical note [N1] and the medical record [A2] indicate that both procedures were performed at the same site during the same session as part of one service. Therefore, the use of modifier 59 is not justified, and the claim is denied for CO97 - Benefit included in another service already adjudicated.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:15 · 65d80d54
Other claims for this member
Same resolved identity
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
- CO97 Benefit included in another service already adjudicated
The claim includes a chest X-ray (71046) and an emergency department visit (99283) with a modifier 59, which are normally bundled services. The clinical note [N1] and the medical record [A2] indicate that both procedures were performed at the same site during the same session as part of one service. Therefore, the use of modifier 59 is not justified, and the claim is denied for CO97 - Benefit included in another service already adjudicated.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
- CO97 Benefit included in another service already adjudicated
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Bundled code pair; modifier 59 not supported by the operative note.