CLM-2026-025518
Summit Community Hospital, Emergency Medicine. Service 2026-04-25 at emergency room (POS 23). Received 2026-04-27.
Member
Resolved through the identity graph
- Member
- Andrea Rivera
- Member ID
- UHC-61214-06
- Date of birth
- 1978-04-11
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-427608
- Relationship
- Spouse, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-5667
- Coverage period
- 2025-04-01 to present
- Deductible
- $1,909.60 of $2,500.0076%
- Out-of-pocket maximum
- $358.75 of $7,500.005%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 19 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 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,585.00 | $871.75 | $250.00 | $621.75 | Paid |
| Totals | $1,585.00 | $871.75 | $250.00 | $621.75 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- Patient account
- PA-127569
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-028036 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-25: NULL (PPO), effective 2025-04-01. | |
| Timely filing | Pass | Received 2 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 Hospital2026-04-25 11:32
Established patient presents with pneumonia, unspecified organism; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-127569.pdf5 pages
Itemised statement totalling $1585.00 across 1 line.
- Er reported_report_PA-127569.pdf6 pages
Emergency department record: triage acuity 3, 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 engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
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.