CLM-2026-023842
Summit Regional Medical Center, Emergency Medicine. Service 2026-08-23 at emergency room (POS 23). Received 2026-09-26.
Member
Resolved through the identity graph
- Member
- Katherine Lucas
- Member ID
- UHC-29115-96
- Date of birth
- 1966-07-23
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-419271
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-1890
- Coverage period
- 2022-08-01 to 2026-01-15
- Deductible
- $2,566.74 of $3,500.0073%
- Out-of-pocket maximum
- $3,026.08 of $14,000.0022%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 3973431752
- Network
- In network
- Rendering NPI
- 3973431752
- Location
- Nashville, TN · TIN 74-3643207
- 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 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,636.00 | $899.80 | — | — | DeniedCO27 |
| Totals | $1,636.00 | $899.80 | — | — | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- Patient account
- PA-258544
- 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-007786 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-23 is after coverage terminated on 2026-01-15. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 34 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 (3973431752). | |
| 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 Regional Medical Center2026-08-23 17:51
Patient seen for pneumonia, unspecified organism.
- SystemSystem: Claims system2026-09-26 02:15
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-09-26 10:42
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-258544.pdf8 pages
Itemised statement totalling $1636.00 across 1 line.
- Er reported_report_PA-258544.pdf2 pages
Emergency department record: triage acuity 3, chief complaint pneumonia, unspecified organism.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-23 is after coverage terminated on 2026-01-15.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016501 | 2026-06-04 | Northgate Heart Institute | $1,247.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.