CLM-2026-024968
Valley Regional Medical Center, Emergency Medicine. Service 2026-02-05 at emergency room (POS 23). Received 2026-03-03.
Member
Resolved through the identity graph
- Member
- Debra Hoffman
- Member ID
- UHC-18077-63
- Date of birth
- 1983-03-20
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-422963
- Relationship
- Spouse, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-5315
- Coverage period
- 2023-07-01 to present
- Deductible
- $78.34 of $3,500.002%
- Out-of-pocket maximum
- $1,167.52 of $7,000.0017%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 16 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 / REF994137
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 | $1,798.00 | $988.90 | $350.00 | $638.90 | Paid |
| Totals | $1,798.00 | $988.90 | $350.00 | $638.90 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. R55 Syncope and collapse
- Patient account
- PA-487798
- Frequency code
- 1 (original)
- Accident
- Yes
- 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-017186 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-05: CORE-HMO (HMO), effective 2023-07-01. | |
| 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 Valley Regional Medical Center (2408607978). | |
| 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: Valley Regional Medical Center2026-02-05 17:54
Follow-up for pneumonia, unspecified organism. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-487798.pdf2 pages
Itemised statement totalling $1798.00 across 1 line.
- Er reported_report_PA-487798.pdf5 pages
Emergency department record: triage acuity 4, chief complaint pneumonia, unspecified organism.
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001204 | 2026-09-28 | Sunrise Imaging Center | $248.00 | 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.