Claims workbench/CLM-2026-032510
Institutional claim · UB-04 · EDI 837I

CLM-2026-032510

Summit Community Hospital, Emergency Medicine. Service 2026-06-11 at emergency room (POS 23). Received 2026-06-14.

PendedIdentity on hold: CASE-004131
Billed
$1,828.00
3 lines
Allowed
$1,005.40
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
IDQ, N30
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Olivia Campbell
Member ID
none on golden record
Date of birth
—
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-409406
Relationship
Self

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Summit Community Hospital
Emergency 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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
171046
rev 0320
Chest X-ray, two views—11$163.00$89.65——PendedIDQ
296374
rev 0260
IV push, single drug2512$244.00$134.20——PendedIDQ
399284
rev 0450
Emergency department visit, high severity—11,2$1,421.00$781.55——PendedIDQ
Totals$1,828.00$1,005.40——
Diagnoses (ICD-10-CM)
  • 1. R55 Syncope and collapseprincipal
  • 2. J18.9 Pneumonia, unspecified organism
  • 3. R07.9 Chest pain, unspecified
Claim header
Patient account
PA-242400
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 3 needing attention

CheckResultCodeDetail
Member identityFailIDQMember record is in open steward case CASE-004131; payment withheld until the identity is confirmed.
Member identity under steward review
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 3 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Summit Community Hospital (7504049959).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessReviewCO16Documentation incomplete: “Established patient presents with syncope and collapse; symptoms reviewed and vitals withi”.
Claim lacks information needed for adjudication
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Summit Community Hospital2026-06-11 10:15

    Established patient presents with syncope and collapse; symptoms reviewed and vitals within expected range. Note dictated; signature pending.

  • SystemSystem: Claims system2026-06-14 06:32

    Rendering provider signature missing on the attached note. Development letter sent to provider.

  • AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-06-14 08:21

    Called the provider office; awaiting documentation.

Attachments

Documents received with the claim

  • Itemized billitemized_PA-242400.pdf5 pages

    Itemised statement totalling $1828.00 across 3 lines.

  • Er reported_report_PA-242400.pdf4 pages

    Emergency department record: triage acuity 4, chief complaint syncope and collapse.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-21 13:43
    Member identity: Member record is in open steward case CASE-004131; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim. Completeness: Documentation incomplete: “Established patient presents with syncope and collapse; symptoms reviewed and vitals withi”.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

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

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

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

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

PendedCO16scenario: Missing info

Development letter outstanding.

Review queueMember identity