Claims workbench/CLM-2026-032825

Institutional claim · UB-04 · EDI 837I

CLM-2026-032825

Valley Regional Medical Center, Emergency Medicine. Service 2026-09-07 at emergency room (POS 23). Received 2026-10-12.

Denied

Billed

$1,083.00

1 line

Allowed

$595.65

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Deny

CO18

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Aisha Cole
Member ID: UHC-86878-50
Date of birth: 1975-04-01
Identity: Verified4 records, confidence 0.99
Claim record: CLMCLM-403428
Relationship: Self, Minneapolis, MN

Coverage and accumulators

Found by member ID

Plan: MEDICARE-ADV-A MA group GRP-5066
Coverage period: 2025-05-01 to present
Deductible: $1,818.89 of $3,500.0052%
Out-of-pocket maximum: $2,737.71 of $14,000.0020%
Copays: office $25.00, specialist $60.00, emergency $350.00
Physical therapy visits: 22 of 20 used

Provider

Billing and rendering

Billing provider: Valley Regional Medical Center
Emergency 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	$1,083.00	$595.65	—	—	DeniedCO18
Totals						$1,083.00	$595.65	—	—

Diagnoses (ICD-10-CM)

1. J18.9 Pneumonia, unspecified organismprincipal
2. R07.9 Chest pain, unspecified
3. R55 Syncope and collapse

Claim header

Patient account: PA-709675
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-030273 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-09-07: MEDICARE-ADV-A (MA), effective 2025-05-01.
Timely filing	Pass		Received 35 days after service (limit 90).
Duplicate check	Fail	CO18	Exact duplicate of CLM-2026-032824: same member, date of service, procedures and billing provider. Exact duplicate claim or service
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.

Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Valley Regional Medical Center2026-09-07 16:07
Patient seen for pneumonia, unspecified organism.
SystemSystem: Claims system2026-10-12 06:22
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-10-12 15:13
Escalated to nurse reviewer for clinical opinion.

Attachments

Documents received with the claim

Itemized billitemized_PA-709675.pdf3 pages
Itemised statement totalling $1083.00 across 1 line.
Er reported_report_PA-709675.pdf6 pages
Emergency department record: triage acuity 3, chief complaint pneumonia, unspecified organism.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Duplicate check: Exact duplicate of CLM-2026-032824: same member, date of service, procedures and billing provider.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-032824	2026-09-07	Valley Regional Medical Center	$1,083.00	Approved
CLM-2026-003521	2026-05-29	Evergreen Orthopedic Specialists	$312.00	Approved

AI recommendation

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

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

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

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

DeniedCO18scenario: Duplicate

Exact duplicate of an earlier submission.

Review queue Member identity