CLM-2026-025222
Valley Community Hospital, Emergency Medicine. Service 2026-03-06 at emergency room (POS 23). Received 2026-03-30.
Member
Resolved through the identity graph
- Member
- Jesse Mendez
- Member ID
- none on golden record
- Date of birth
- 1971-07-20
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-416912
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by name and date of birth
- Plan
- CORE-HMO HMO group GRP-0850
- Coverage period
- 2024-08-01 to present
- Deductible
- $1,880.32 of $3,500.0054%
- Out-of-pocket maximum
- $3,040.97 of $14,000.0022%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 3406943738
- Network
- Out of network
- Rendering NPI
- 3406943738
- Location
- Austin, TX · TIN 13-2256808
- Authorisation / referral
- none / REF180769
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 | $193.00 | $106.15 | — | — | PendedIDQ |
| Totals | $193.00 | $106.15 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. J18.9 Pneumonia, unspecified organism
- Patient account
- PA-406860
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-001194; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-03-06: CORE-HMO (HMO), effective 2024-08-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 24 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 | Review | NET | Out-of-network emergency visit. Payable at the in-network level if the prudent-layperson standard is met; review the ED record. Out-of-network provider |
| 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 Community Hospital2026-03-06 16:09
Patient seen for chest pain, unspecified. Patient presented to the nearest emergency department with acute symptoms; care could not safely be delayed to reach an in-network facility.
- SystemSystem: Claims system2026-03-30 06:55
Out-of-network emergency visit. Emergency services are payable at the in-network level when the prudent-layperson standard is met.
Attachments
Documents received with the claim
- Itemized billitemized_PA-406860.pdf3 pages
Itemised statement totalling $193.00 across 1 line.
- Er reported_report_PA-406860.pdf5 pages
Emergency department record: triage acuity 3, chief complaint chest pain, unspecified.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-001194; payment withheld until the identity is confirmed. Eligibility: Active on 2026-03-06: CORE-HMO (HMO), effective 2024-08-01. Coverage found by name and date of birth because the claim carried no usable member ID. Provider network: Out-of-network emergency visit. Payable at the in-network level if the prudent-layperson standard is met; review the ED record.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Emergency: payable at in-network level.