CLM-2026-025653
Valley Community Hospital, Emergency Medicine. Service 2026-07-20 at emergency room (POS 23). Received 2026-08-12.
Member
Resolved through the identity graph
- Member
- Arjun Robertson
- Member ID
- UHC-87084-84
- Date of birth
- 1980-11-11
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-416407
- Relationship
- Child, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-5962
- Coverage period
- 2022-04-01 to 2026-03-18
- Deductible
- $96.87 of $500.0019%
- Out-of-pocket maximum
- $476.91 of $1,000.0048%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 11 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 / 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 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $880.00 | $396.00 | — | — | DeniedCO27 |
| Totals | $880.00 | $396.00 | — | — | ||||||
- 1. R55 Syncope and collapseprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-896630
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-009602 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-20 is after coverage terminated on 2026-03-18. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 23 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Hospital2026-07-20 18:03
Established patient presents with syncope and collapse; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-12 02:25
Attachments
Documents received with the claim
- Itemized billitemized_PA-896630.pdf4 pages
Itemised statement totalling $880.00 across 1 line.
- Er reported_report_PA-896630.pdf3 pages
Emergency department record: triage acuity 4, chief complaint syncope and collapse.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-07-20 is after coverage terminated on 2026-03-18. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007688 | 2026-07-13 | Evergreen Family Practice | $569.00 | Denied |
| CLM-2026-023206 | 2026-01-08 | Heritage Physical Therapy | $400.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.