Claims workbench/CLM-2026-026409

Institutional claim · UB-04 · EDI 837I

CLM-2026-026409

Meadow Regional Medical Center, Emergency Medicine. Service 2026-08-04 at emergency room (POS 23). Received 2026-08-20.

Needs review

Billed

$1,381.00

3 lines

Allowed

$759.55

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Review

CO16

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Samuel Mitchell
Member ID: UHC-84599-11
Date of birth: 1982-03-18
Identity: Verified3 records, confidence 0.99
Claim record: CLMCLM-406830
Relationship: Spouse, Las Vegas, NV

Coverage and accumulators

Found by member ID

Plan: MEDICARE-ADV-A MA group GRP-4038
Coverage period: 2021-01-01 to present
Deductible: $112.26 of $1,000.0011%
Out-of-pocket maximum: $1,021.50 of $3,000.0034%
Copays: office $25.00, specialist $60.00, emergency $350.00
Physical therapy visits: 3 of 20 used

Provider

Billing and rendering

Billing provider: Meadow Regional Medical Center
Emergency Medicine · taxonomy 207P00000X
NPI: 1905050427
Network: In network
Rendering NPI: 1905050427
Location: Dallas, TX · TIN 71-2312931
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	71046 rev 0320	Chest X-ray, two views	—	1	1	$199.00	$109.45	—	—	Review
2	99283 rev 0450	Emergency department visit, moderate severity	—	1	1,2	$1,005.00	$552.75	—	—	Review
3	96374 rev 0260	IV push, single drug	—	1	1,2	$177.00	$97.35	—	—	Review
Totals						$1,381.00	$759.55	—	—

Diagnoses (ICD-10-CM)

1. R55 Syncope and collapseprincipal
2. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
3. R10.9 Unspecified abdominal pain

Claim header

Patient account: PA-809575
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-027107 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-08-04: MEDICARE-ADV-A (MA), effective 2021-01-01.
Timely filing	Pass		Received 16 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 Meadow Regional Medical Center (1905050427).
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: “Established patient presents with syncope and collapse; symptoms reviewed and vitals withi”. Claim lacks information needed for adjudication
High-dollar review	Pass		Within the auto-adjudication ceiling.

Evaluated 2026-10-21 13:43 under policy version 1. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Meadow Regional Medical Center2026-08-04 13:01
Established patient presents with syncope and collapse; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
SystemSystem: Claims system2026-08-20 01:32
Rendering provider signature missing on the attached note. Development letter sent to provider.
AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-08-20 14:04
Escalated to nurse reviewer for clinical opinion.

Attachments

Documents received with the claim

Itemized billitemized_PA-809575.pdf6 pages
Itemised statement totalling $1381.00 across 3 lines.
Er reported_report_PA-809575.pdf6 pages
Emergency department record: triage acuity 2, chief complaint syncope and collapse.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Completeness: Documentation incomplete: “Established patient presents with syncope and collapse; symptoms reviewed and vitals withi”.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-012258	2026-06-22	Lakeside Reference Lab	$2,194.00	Needs review

AI recommendation

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

The rules engine left this claim for review. The AI adjudicator can read the evidence pack (lines, notes, attachments, coverage, history) and recommend an outcome with citations.

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