Claims workbench/CLM-2026-026184

Institutional claim · UB-04 · EDI 837I

CLM-2026-026184

Summit Regional Medical Center, Emergency Medicine. Service 2026-02-27 at emergency room (POS 23). Received 2026-04-02.

PendedIdentity on hold: CASE-003336

Billed

$3,741.00

2 lines

Allowed

$2,057.55

if approved

Plan pays

—

Pended

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Pend

IDQ

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Sean Ramirez
Member ID: UHC-19509-62
Date of birth: 2007-05-18
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-401884
Relationship: Self

Coverage and accumulators

Found by member ID

Plan: MEDICARE-ADV-A MA group GRP-3971
Coverage period: 2025-07-01 to present
Deductible: $942.18 of $1,500.0063%
Out-of-pocket maximum: $1,450.29 of $3,000.0048%
Copays: office $20.00, specialist $60.00, emergency $150.00
Physical therapy visits: 15 of 20 used

Provider

Billing and rendering

Billing provider: Summit Regional Medical Center
Emergency Medicine · taxonomy 207P00000X
NPI: 7959926214
Network: In network
Rendering NPI: 7959926214
Location: Mesa, AZ · TIN 13-8570749
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	99285 rev 0450	Emergency department visit, high severity with threat to life	—	1	1	$2,957.00	$1,626.35	—	—	PendedIDQ
2	99283 rev 0450	Emergency department visit, moderate severity	—	1	1,2	$784.00	$431.20	—	—	PendedIDQ
Totals						$3,741.00	$2,057.55	—	—

Diagnoses (ICD-10-CM)

1. S93.401A Sprain of unspecified ligament of right ankle, initial encounterprincipal
2. R07.9 Chest pain, unspecified

Claim header

Patient account: PA-981286
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	Fail	IDQ	Member record is in open steward case CASE-003336; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Pass		Active on 2026-02-27: MEDICARE-ADV-A (MA), effective 2025-07-01.
Timely filing	Pass		Received 34 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 Regional Medical Center (7959926214).
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Pass		No bundling conflicts.
Benefit limits	Pass		No limited benefit on this claim.
Completeness	Review	CO16	Documentation incomplete: “Patient seen for sprain of unspecified ligament of right ankle, initial encounter. Note di”. Claim lacks information needed for adjudication
High-dollar review	Pass		Within the auto-adjudication ceiling.

Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Summit Regional Medical Center2026-02-27 18:35
Patient seen for sprain of unspecified ligament of right ankle, initial encounter. Note dictated; signature pending.
SystemSystem: Claims system2026-04-02 03:38
Rendering provider signature missing on the attached note. Development letter sent to provider.
AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-04-02 15:54
Escalated to nurse reviewer for clinical opinion.

Attachments

Documents received with the claim

Itemized billitemized_PA-981286.pdf6 pages
Itemised statement totalling $3741.00 across 2 lines.
Er reported_report_PA-981286.pdf3 pages
Emergency department record: triage acuity 3, chief complaint sprain of unspecified ligament of right ankle, initial encounter.

Claim history

Every event on this claim, sealed in the audit chain

Rules enginePended2026-10-22 12:44
Member identity: Member record is in open steward case CASE-003336; payment withheld until the identity is confirmed. Completeness: Documentation incomplete: “Patient seen for sprain of unspecified ligament of right ankle, initial encounter. Note di”.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

PendedCO16scenario: Missing info

Development letter outstanding.

Review queue Member identity