Claims workbench/CLM-2026-027433

Institutional claim · UB-04 · EDI 837I

CLM-2026-027433

Summit Regional Medical Center, Emergency Medicine. Service 2026-04-12 at emergency room (POS 23). Received 2026-05-30.

Denied

Billed

$3,661.00

2 lines

Allowed

$2,013.55

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO18

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Mei Walsh
Member ID: UHC-98864-36
Date of birth: 1980-04-15
Identity: Verified4 records, confidence 1.00
Claim record: CLMCLM-430044
Relationship: Self, Orlando, FL

Coverage and accumulators

Found by member ID

Plan: NAVIGATE-HMO HMO group GRP-0871
Coverage period: 2022-10-01 to present
Deductible: $1,015.24 of $1,500.0068%
Out-of-pocket maximum: $2,080.50 of $4,500.0046%
Copays: office $30.00, specialist $75.00, emergency $350.00
Physical therapy visits: 20 of 20 used

Provider

Billing and rendering

Billing provider: Summit Regional Medical Center
Emergency Medicine · taxonomy 207P00000X
NPI: 1269847210
Network: In network
Rendering NPI: 1269847210
Location: Mesa, AZ · TIN 62-8021640
Authorisation / referral: none / REF415273

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	$2,701.00	$1,485.55	—	—	DeniedCO18
2	99283 rev 0450	Emergency department visit, moderate severity	25	1	1	$960.00	$528.00	—	—	DeniedCO18
Totals						$3,661.00	$2,013.55	—	—

Diagnoses (ICD-10-CM)

1. S93.401A Sprain of unspecified ligament of right ankle, initial encounterprincipal

Claim header

Patient account: PA-113534
Frequency code: 1 (original)
Accident: Yes
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-018523 (verified, link confidence 1.00).
Eligibility	Pass		Active on 2026-04-12: NAVIGATE-HMO (HMO), effective 2022-10-01.
Timely filing	Pass		Received 48 days after service (limit 90).
Duplicate check	Fail	CO18	Exact duplicate of CLM-2026-027432: same member, date of service, procedures and billing provider. Exact duplicate claim or service
Prior authorisation	Pass		No line requires precertification.
Provider network	Pass		In-network provider Summit Regional Medical Center (1269847210).
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.

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

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Summit Regional Medical Center2026-04-12 18:59
Patient seen for sprain of unspecified ligament of right ankle, initial encounter.
SystemSystem: Claims system2026-05-30 01:16
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-05-30 16:46
Called the provider office; awaiting documentation.

Attachments

Documents received with the claim

Itemized billitemized_PA-113534.pdf5 pages
Itemised statement totalling $3661.00 across 2 lines.
Er reported_report_PA-113534.pdf4 pages
Emergency department record: triage acuity 2, chief complaint sprain of unspecified ligament of right ankle, initial encounter.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-22 12:44
Duplicate check: Exact duplicate of CLM-2026-027432: same member, date of service, procedures and billing provider.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-027432	2026-04-12	Summit Regional Medical Center	$3,661.00	Approved
CLM-2026-004769	2026-02-07	Lakeside Medical Group	$350.00	Approved

AI recommendation

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

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

Examiner decision

Denied by Claims rules engine; an examiner may still override

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

DeniedCO18scenario: Duplicate

Exact duplicate of an earlier submission.

Review queue Member identity