CLM-2026-026879
Summit Community Hospital, Emergency Medicine. Service 2026-08-04 at emergency room (POS 23). Received 2026-08-27.
Member
Resolved through the identity graph
- Member
- Eric Schmidt
- Member ID
- UHC-94650-89
- Date of birth
- 1945-11-23
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-416389
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-9328
- Coverage period
- 2024-08-01 to present
- Deductible
- $142.32 of $1,000.0014%
- Out-of-pocket maximum
- $599.62 of $4,000.0015%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 11 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 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,131.00 | $622.05 | $150.00 | $472.05 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | 25 | 1 | 1 | $252.00 | $138.60 | $0.00 | $138.60 | Paid |
| Totals | $1,383.00 | $760.65 | $150.00 | $610.65 | ||||||
- 1. R55 Syncope and collapseprincipal
- 2. J18.9 Pneumonia, unspecified organism
- Patient account
- PA-458032
- 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-005264 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-08-04: MEDICARE-ADV-A (MA), effective 2024-08-01. | |
| Timely filing | Pass | Received 23 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 Hospital2026-08-04 16:01
Follow-up for syncope and collapse. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-458032.pdf8 pages
Itemised statement totalling $1383.00 across 2 lines.
- Er reported_report_PA-458032.pdf3 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 engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024813 | 2026-08-23 | Harbor Physical Therapy | $340.00 | Denied |
| CLM-2026-024812 | 2026-08-23 | Harbor Physical Therapy | $340.00 | Approved |
| CLM-2026-022204 | 2026-07-24 | Sunrise Counseling Center | $434.00 | Approved |
| CLM-2026-020821 | 2026-05-22 | Sunrise Cardiovascular Associates | $8,850.00 | Approved |
| CLM-2026-011139 | 2025-12-15 | Mesa Regional Medical Center | $328.00 | 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.