CLM-2026-024974
Summit Community Hospital, Emergency Medicine. Service 2026-08-23 at emergency room (POS 23). Received 2026-09-28.
Member
Resolved through the identity graph
- Member
- Amber Walker
- Member ID
- UHC-16667-35
- Date of birth
- 1987-09-21
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-431679
- Relationship
- Spouse, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-1509
- Coverage period
- 2025-02-01 to present
- Deductible
- $369.04 of $1,500.0025%
- Out-of-pocket maximum
- $1,392.33 of $4,500.0031%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 1 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 | $2,365.00 | $1,300.75 | $250.00 | $1,050.75 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1,2 | $184.00 | $101.20 | $0.00 | $101.20 | Paid |
| 3 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $867.00 | $476.85 | $0.00 | $476.85 | Paid |
| Totals | $3,416.00 | $1,878.80 | $250.00 | $1,628.80 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. J18.9 Pneumonia, unspecified organism
- 3. R07.9 Chest pain, unspecified
- Patient account
- PA-135449
- 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-022756 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-23: SELECT-EPO (EPO), effective 2025-02-01. | |
| 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 Hospital2026-08-23 09:55
Patient seen for unspecified abdominal pain.
Attachments
Documents received with the claim
- Itemized billitemized_PA-135449.pdf4 pages
Itemised statement totalling $3416.00 across 3 lines.
- Er reported_report_PA-135449.pdf4 pages
Emergency department record: triage acuity 2, chief complaint unspecified abdominal pain.
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-2026-022437 | 2026-05-04 | Unity Digestive Health Center | $2,000.00 | 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.