CLM-2026-026096
Valley Regional Medical Center, Emergency Medicine. Service 2026-02-04 at emergency room (POS 23). Received 2026-03-02.
Member
Resolved through the identity graph
- Member
- Maria Little
- Member ID
- UHC-16279-83
- Date of birth
- 1969-04-02
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-406213
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-6770
- Coverage period
- 2022-09-01 to 2026-07-04
- Deductible
- $823.42 of $3,500.0024%
- Out-of-pocket maximum
- $898.27 of $7,000.0013%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 19 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 | $225.00 | $123.75 | $123.75 | $0.00 | Paid |
| 2 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 2 | $2,121.00 | $1,166.55 | $0.00 | $1,166.55 | Paid |
| Totals | $2,346.00 | $1,290.30 | $123.75 | $1,166.55 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- Patient account
- PA-381495
- 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-016816 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-04: MEDICARE-ADV-A (MA), effective 2022-09-01, terms 2026-07-04. | |
| Timely filing | Pass | Received 26 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 Center2026-02-04 10:19
Patient seen for unspecified abdominal pain.
Attachments
Documents received with the claim
- Itemized billitemized_PA-381495.pdf5 pages
Itemised statement totalling $2346.00 across 2 lines.
- Er reported_report_PA-381495.pdf6 pages
Emergency department record: triage acuity 4, 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
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.