CLM-2026-024983
Valley Regional Medical Center, Emergency Medicine. Service 2026-04-26 at emergency room (POS 23). Received 2026-06-02.
Member
Resolved through the identity graph
- Member
- Megan Allen
- Member ID
- UHC-94421-04
- Date of birth
- 1946-09-15
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-425920
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-9282
- Coverage period
- 2025-08-01 to present
- Deductible
- $673.78 of $2,500.0027%
- Out-of-pocket maximum
- $2,986.90 of $10,000.0030%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 18 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 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $175.00 | $96.25 | $96.25 | $0.00 | Paid |
| Totals | $175.00 | $96.25 | $96.25 | $0.00 | ||||||
- 1. R55 Syncope and collapseprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-422137
- 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-004533 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-26: MEDICARE-ADV-A (MA), effective 2025-08-01. | |
| Timely filing | Pass | Received 37 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 Center2026-04-26 13:40
Patient seen for syncope and collapse.
Attachments
Documents received with the claim
- Itemized billitemized_PA-422137.pdf8 pages
Itemised statement totalling $175.00 across 1 line.
- Er reported_report_PA-422137.pdf4 pages
Emergency department record: triage acuity 3, chief complaint syncope and collapse.
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-2026-006003 | 2026-08-05 | Sunrise Medical Group | $363.00 | Approved |
| CLM-2026-033669 | 2026-06-28 | Harbor Primary Care Associates | $413.00 | Approved |
| CLM-2026-015422 | 2026-05-09 | Harbor Clinical Laboratories | $39.00 | Needs review |
| CLM-2026-015421 | 2026-05-09 | Valley Reference Lab | $39.00 | 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.