CLM-2026-033458
Summit Regional Medical Center, Emergency Medicine. Service 2026-01-18 at emergency room (POS 23). Received 2026-02-22.
Member
Resolved through the identity graph
- Member
- Michelle Lynch
- Member ID
- UHC-07856-55
- Date of birth
- 1967-09-11
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-431328
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-3767
- Coverage period
- 2025-03-01 to present
- Deductible
- $2,014.66 of $2,500.0081%
- Out-of-pocket maximum
- $9.97 of $7,500.000%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 1269847210
- Network
- In network
- Rendering NPI
- 1269847210
- Location
- Mesa, AZ · TIN 62-8021640
- Authorisation / referral
- none / REF470384
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 | $231.00 | $127.05 | $127.05 | $0.00 | Paid |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | 25 | 1 | 1 | $947.00 | $520.85 | $0.00 | $520.85 | Paid |
| Totals | $1,178.00 | $647.90 | $127.05 | $520.85 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-723631
- Frequency code
- 1 (original)
- Accident
- Yes
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-011703 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-18: NAVIGATE-HMO (HMO), effective 2025-03-01. | |
| 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 Summit Regional Medical Center (1269847210). | |
| 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: Summit Regional Medical Center2026-01-18 11:18
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-723631.pdf9 pages
Itemised statement totalling $1178.00 across 2 lines.
- Er reported_report_PA-723631.pdf3 pages
Emergency department record: triage acuity 4, chief complaint chest pain, unspecified.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033459 | 2026-01-18 | Unity Community Hospital | $1,178.00 | Needs review |
| CLM-2026-026140 | 2026-01-06 | Cornerstone Bone and Joint Center | $46,692.00 | Denied |
| CLM-2026-026139 | 2026-01-06 | Cornerstone Bone and Joint Center | $46,692.00 | Needs review |
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.