CLM-2026-031601
Valley Community Hospital, Emergency Medicine. Service 2026-05-27 at emergency room (POS 23). Received 2026-07-10.
Member
Resolved through the identity graph
- Member
- Victoria Hunt
- Member ID
- UHC-04238-66
- Date of birth
- 1978-03-28
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-400856
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-6723
- Coverage period
- 2021-04-01 to present
- Deductible
- $938.10 of $2,500.0038%
- Out-of-pocket maximum
- $4,409.72 of $10,000.0044%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 3406943738
- Network
- Out of network
- Rendering NPI
- 3406943738
- Location
- Austin, TX · TIN 13-2256808
- 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 | $217.00 | $97.65 | $97.65 | $0.00 | Paid |
| 2 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $2,346.00 | $1,055.70 | $0.00 | $1,055.70 | Paid |
| Totals | $2,563.00 | $1,153.35 | $97.65 | $1,055.70 | ||||||
- 1. R55 Syncope and collapseprincipal
- Patient account
- PA-202573
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-018632 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-27: MEDICARE-ADV-B (MA), effective 2021-04-01. | |
| Timely filing | Pass | Received 44 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Community Hospital2026-05-27 13:19
Established patient presents with syncope and collapse; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-202573.pdf7 pages
Itemised statement totalling $2563.00 across 2 lines.
- Er reported_report_PA-202573.pdf6 pages
Emergency department record: triage acuity 4, 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 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023259 | 2026-07-05 | Unity Reference Lab | $190.00 | Approved |
| CLM-2026-013713 | 2026-06-17 | Mesa Family Practice | $212.00 | 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.