Claims workbench/CLM-2026-034499

Institutional claim · UB-04 · Provider portal

CLM-2026-034499

Valley Regional Medical Center, Emergency Medicine. Service 2026-07-16 at emergency room (POS 23). Received 2026-08-04.

PendedIdentity on hold: CASE-002512

Billed

$934.00

2 lines

Allowed

$513.70

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: Ronald Espinoza
Member ID: none on golden record
Date of birth: 1971-03-13
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-420384
Relationship: Child, Nashville, TN

Coverage and accumulators

Eligibility

No coverage segment found for this member.

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	$718.00	$394.90	—	—	PendedIDQ
2	96374 rev 0260	IV push, single drug	—	1	1	$216.00	$118.80	—	—	PendedIDQ
Totals						$934.00	$513.70	—	—

Diagnoses (ICD-10-CM)

1. S93.401A Sprain of unspecified ligament of right ankle, initial encounterprincipal
2. J18.9 Pneumonia, unspecified organism
3. R07.9 Chest pain, unspecified

Claim header

Patient account: PA-106223
Frequency code: 1 (original)
Accident: Yes
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

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-002512; 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 19 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	Review	CO16	Documentation incomplete: “Patient seen for sprain of unspecified ligament of right ankle, initial encounter. Note di”. Claim lacks information needed for adjudication
High-dollar review	Pass		Within 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: Valley Regional Medical Center2026-07-16 10:06
Patient seen for sprain of unspecified ligament of right ankle, initial encounter. Note dictated; signature pending.
SystemSystem: Claims system2026-08-04 05:46
Rendering provider signature missing on the attached note. Development letter sent to provider.

Attachments

Documents received with the claim

Itemized billitemized_PA-106223.pdf7 pages
Itemised statement totalling $934.00 across 2 lines.
Er reported_report_PA-106223.pdf5 pages
Emergency department record: triage acuity 2, chief complaint sprain of unspecified ligament of right ankle, initial encounter.

Claim history

Every event on this claim, sealed in the audit chain

Rules enginePended2026-10-21 13:43
Member identity: Member record is in open steward case CASE-002512; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim. Completeness: Documentation incomplete: “Patient seen for sprain of unspecified ligament of right ankle, initial encounter. Note di”.

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

PendedCO16scenario: Missing info

Development letter outstanding.

Review queue Member identity