CLM-2026-032748
Valley Regional Medical Center, Emergency Medicine. Service 2026-05-23 at emergency room (POS 23). Received 2026-06-27.
Member
Resolved through the identity graph
- Member
- Tyler Young
- Member ID
- UHC-00161-11
- Date of birth
- 1980-07-21
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-406588
- Relationship
- Spouse, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-4148
- Coverage period
- 2021-08-01 to present
- Deductible
- $2,539.56 of $3,500.0073%
- Out-of-pocket maximum
- $2,021.99 of $14,000.0014%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 15 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 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $924.00 | $508.20 | $250.00 | $258.20 | Paid |
| 2 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $213.00 | $117.15 | $0.00 | $117.15 | Paid |
| Totals | $1,137.00 | $625.35 | $250.00 | $375.35 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- Patient account
- PA-587514
- Frequency code
- 1 (original)
- Accident
- Yes
- 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-035788 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-05-23: OPTIONS-PPO (PPO), effective 2021-08-01. | |
| Timely filing | Pass | Received 35 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 Center2026-05-23 10:49
Follow-up for pneumonia, unspecified organism. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-587514.pdf6 pages
Itemised statement totalling $1137.00 across 2 lines.
- Er reported_report_PA-587514.pdf3 pages
Emergency department record: triage acuity 4, chief complaint pneumonia, unspecified organism.
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.