CLM-2026-026300
Valley Community Hospital, Emergency Medicine. Service 2025-12-12 at emergency room (POS 23). Received 2026-01-11.
Member
Resolved through the identity graph
- Member
- Wayne Nelson
- Member ID
- UHC-16289-79
- Date of birth
- 2003-08-18
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-423597
- Relationship
- Spouse, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-5501
- Coverage period
- 2021-08-01 to 2026-08-20
- Deductible
- $377.08 of $1,500.0025%
- Out-of-pocket maximum
- $2,238.37 of $4,500.0050%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- 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 / 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 | $955.00 | $429.75 | $150.00 | $279.75 | Paid |
| Totals | $955.00 | $429.75 | $150.00 | $279.75 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-784658
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-003211 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-12-12: MEDICARE-ADV-A (MA), effective 2021-08-01, terms 2026-08-20. | |
| Timely filing | Pass | Received 30 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 Hospital2025-12-12 13:22
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-784658.pdf5 pages
Itemised statement totalling $955.00 across 1 line.
- Er reported_report_PA-784658.pdf2 pages
Emergency department record: triage acuity 3, 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 engineApproved2026-10-22 12:44Provider 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-2026-020241 | 2026-05-29 | Northgate Imaging Center | $375.00 | Approved |
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.