Claims workbench/CLM-2026-033893

Institutional claim · UB-04 · EDI 837I

CLM-2026-033893

Summit Community Hospital, Emergency Medicine. Service 2026-05-14 at emergency room (POS 23). Received 2026-06-19.

PendedIdentity on hold: CASE-003405

Billed

$2,870.00

2 lines

Allowed

$1,578.50

if approved

Plan pays

—

Pended

Member owes

—

no coverage

Rules engine

Pend

IDQ, N30

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Romero Katherine
Member ID: none on golden record
Date of birth: 1960-05-18
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-410172
Relationship: Self, Plano, TX

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

Line	Code	Description	Mod.	Units	Dx	Billed	Allowed	Member	Plan	Line status
1	99285 rev 0450	Emergency department visit, high severity with threat to life	59	1	1	$2,621.00	$1,441.55	—	—	PendedIDQ
2	96374 rev 0260	IV push, single drug	59	1	2	$249.00	$136.95	—	—	PendedIDQ
Totals						$2,870.00	$1,578.50	—	—

Diagnoses (ICD-10-CM)

1. J18.9 Pneumonia, unspecified organismprincipal

Claim header

Patient account: PA-948852
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 3 needing attention

Check	Result	Code	Detail
Member identity	Fail	IDQ	Member record is in open steward case CASE-003405; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Fail	N30	No coverage segment found for the member ID on this claim. Patient ineligible for this service
Timely filing	Pass		Received 36 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 Community Hospital (7504049959).
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Review	CO97	Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated
Benefit limits	Pass		No limited benefit on this claim.
Completeness	Pass		Required documentation present.
High-dollar review	Pass		Within the auto-adjudication ceiling.

Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Summit Community Hospital2026-05-14 13:38
Established patient presents with pneumonia, unspecified organism; symptoms reviewed and vitals within expected range. Both procedures were performed at the same site during the same session as part of one service.
SystemSystem: Claims system2026-06-19 06:45
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.

Attachments

Documents received with the claim

Itemized billitemized_PA-948852.pdf8 pages
Itemised statement totalling $2870.00 across 2 lines.
Medical recordrecords_PA-948852.pdf14 pages
Operative note describes a single procedure at one site; no separate session.
Er reported_report_PA-948852.pdf2 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 enginePended2026-10-22 12:44
Member identity: Member record is in open steward case CASE-003405; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim. Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.

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

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

DeniedCO97scenario: Unbundling

Bundled code pair; modifier 59 not supported by the operative note.

Review queue Member identity