CLM-2026-026695
Summit Community Hospital, Emergency Medicine. Service 2026-01-07 at emergency room (POS 23). Received 2026-02-21.
Member
Resolved through the identity graph
- Member
- Kevin Singh
- Member ID
- UHC-44191-84
- Date of birth
- 1994-08-20
- Identity
- Verified6 records, confidence 0.97
- Claim record
- CLMCLM-423592
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-0864
- Coverage period
- 2023-01-01 to present
- Deductible
- $445.82 of $500.0089%
- Out-of-pocket maximum
- $505.80 of $2,000.0025%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 7504049959
- Network
- In network
- Rendering NPI
- 7504049959
- Location
- Austin, TX · TIN 97-1362073
- 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 | $241.00 | $132.55 | $132.55 | $0.00 | Paid |
| 2 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | 25 | 1 | 1 | $2,558.00 | $1,406.90 | $0.00 | $1,406.90 | Paid |
| 3 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $192.00 | $105.60 | $0.00 | $105.60 | Paid |
| Totals | $2,991.00 | $1,645.05 | $132.55 | $1,512.50 | ||||||
- 1. R55 Syncope and collapseprincipal
- 2. J18.9 Pneumonia, unspecified organism
- Patient account
- PA-760468
- Frequency code
- 1 (original)
- Accident
- Yes
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-004924 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-07: MEDICARE-ADV-A (MA), effective 2023-01-01. | |
| Timely filing | Pass | Received 45 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 Community Hospital (7504049959). | |
| 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: Summit Community Hospital2026-01-07 14:07
Follow-up for syncope and collapse. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-760468.pdf6 pages
Itemised statement totalling $2991.00 across 3 lines.
- Er reported_report_PA-760468.pdf5 pages
Emergency department record: triage acuity 2, chief complaint syncope and collapse.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019722 | 2026-07-18 | Canyon Clinical Laboratories | $185.00 | Approved |
| CLM-2026-005287 | 2026-07-15 | Sunrise Medical Group | $170.00 | Approved |
| CLM-2026-029142 | 2026-06-09 | Mesa Behavioral Health | $418.00 | 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.