CLM-2026-031166
Summit Community Hospital, Emergency Medicine. Service 2026-08-14 at emergency room (POS 23). Received 2026-09-11.
Member
Resolved through the identity graph
- Member
- Carolyn Jordan
- Member ID
- UHC-84537-40
- Date of birth
- 1952-10-12
- Identity
- Verified5 records, confidence 0.94
- Claim record
- CLMCLM-415415
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-0495
- Coverage period
- 2021-08-01 to present
- Deductible
- $1,770.03 of $2,500.0071%
- Out-of-pocket maximum
- $1,712.34 of $5,000.0034%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 20 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 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $777.00 | $427.35 | $250.00 | $177.35 | Paid |
| Totals | $777.00 | $427.35 | $250.00 | $177.35 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-448478
- 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-005316 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2026-08-14: MEDICARE-ADV-B (MA), effective 2021-08-01. | |
| Timely filing | Pass | Received 28 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 Hospital2026-08-14 15:47
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-448478.pdf6 pages
Itemised statement totalling $777.00 across 1 line.
- Er reported_report_PA-448478.pdf6 pages
Emergency department record: triage acuity 4, 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 engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-013455 | 2026-09-24 | Pinecrest Medical Group | $396.00 | Needs review |
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.