Claims workbench/CLM-2026-032195
Institutional claim · UB-04 · EDI 837I

CLM-2026-032195

Summit Regional Medical Center, Emergency Medicine. Service 2026-07-20 at emergency room (POS 23). Received 2026-08-29.

Approved
Billed
$170.00
1 line
Allowed
$93.50
contract rate applied
Plan pays
$0.00
approved
Member owes
$93.50
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Philip Montgomery
Member ID
UHC-95197-13
Date of birth
1947-11-16
Identity
Verified4 records, confidence 0.99
Claim record
CLMCLM-409957
Relationship
Self, San Antonio, TX

Coverage and accumulators

Found by member ID

Plan
MEDICARE-ADV-B MA group GRP-4618
Coverage period
2022-01-01 to present
Deductible
$222.28 of $500.0044%
Out-of-pocket maximum
$528.30 of $2,000.0026%
Copays
office $20.00, specialist $60.00, emergency $150.00
Physical therapy visits
17 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 / none

Service lines

UB-04: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
196374
rev 0260
IV push, single drug—11$170.00$93.50$93.50$0.00Paid
Totals$170.00$93.50$93.50$0.00
Diagnoses (ICD-10-CM)
  • 1. R07.9 Chest pain, unspecifiedprincipal
Claim header
Patient account
PA-936398
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

CheckResultCodeDetail
Member identityPassAttached to MBR-007069 (verified, link confidence 0.99).
EligibilityPassActive on 2026-07-20: MEDICARE-ADV-B (MA), effective 2022-01-01.
Timely filingPassReceived 40 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Summit Regional Medical Center (1269847210).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Summit Regional Medical Center2026-07-20 16:44

    Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.

Attachments

Documents received with the claim

  • Itemized billitemized_PA-936398.pdf2 pages

    Itemised statement totalling $170.00 across 1 line.

  • Er reported_report_PA-936398.pdf6 pages

    Emergency department record: triage acuity 3, chief complaint chest pain, unspecified.

Explanation of benefits

What the member will see

Amount billed
$170.00
Plan discount
$76.50
contracted rate
Plan paid
$0.00
You may owe
$93.50
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-22 12:44
    Clean claim.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

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

Clean claim: the rules engine approved it, so no AI review was needed.

Examiner decision

Approved by Claims rules engine; an examiner may still override

Outcome
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

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queueMember identity