CLM-2026-030594
Valley Regional Medical Center, Emergency Medicine. Service 2026-05-28 at emergency room (POS 23). Received 2026-06-20.
Member
Resolved through the identity graph
- Member
- Matt Brooks
- Member ID
- UHC-65253-69
- Date of birth
- 1971-08-14
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-425334
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8627
- Coverage period
- 2023-05-01 to present
- Deductible
- $573.05 of $2,500.0023%
- Out-of-pocket maximum
- $1,662.26 of $7,500.0022%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 2408607978
- Network
- In network
- Rendering NPI
- 2408607978
- Location
- Austin, TX · TIN 89-0699789
- 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 | $1,335.00 | $734.25 | $350.00 | $384.25 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | 25 | 1 | 1 | $194.00 | $106.70 | $0.00 | $106.70 | Paid |
| 3 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $1,095.00 | $602.25 | $0.00 | $602.25 | Paid |
| Totals | $2,624.00 | $1,443.20 | $350.00 | $1,093.20 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-901508
- Frequency code
- 1 (original)
- Accident
- No
- 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-035577 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-28: SELECT-EPO (EPO), effective 2023-05-01. | |
| 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 Valley Regional Medical Center (2408607978). | |
| 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 Regional Medical Center2026-05-28 13:21
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-901508.pdf4 pages
Itemised statement totalling $2624.00 across 3 lines.
- Er reported_report_PA-901508.pdf3 pages
Emergency department record: triage acuity 2, 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 12:44Clean claim.
Other claims for this member
Same resolved identity
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.