CLM-2026-000602
Riverside Regional Medical Center, Emergency Medicine. Service 2026-01-17 at emergency room (POS 23). Received 2026-02-21.
Member
Resolved through the identity graph
- Member
- Donald Cole
- Member ID
- UHC-90325-35
- Date of birth
- 2002-06-28
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-400023
- Relationship
- Child, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-8912
- Coverage period
- 2025-06-01 to present
- Deductible
- $20.54 of $500.004%
- Out-of-pocket maximum
- $850.15 of $2,000.0043%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 5185579187
- Network
- Out of network
- Rendering NPI
- 5185579187
- Location
- Tempe, AZ · TIN 24-5730797
- 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $177.00 | $79.65 | $79.65 | $0.00 | Paid |
| 2 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $217.00 | $97.65 | $0.00 | $97.65 | Paid |
| 3 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 2 | $1,660.00 | $747.00 | $0.00 | $747.00 | Paid |
| Totals | $2,054.00 | $924.30 | $79.65 | $844.65 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. R55 Syncope and collapse
- Patient account
- PA-982650
- Frequency code
- 1 (original)
- Accident
- Yes
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-014712 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-17: NULL (PPO), effective 2025-06-01. | |
| 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Riverside Regional Medical Center2026-01-17 16:51
Patient seen for unspecified abdominal pain.
Attachments
Documents received with the claim
- Itemized billitemized_PA-982650.pdf9 pages
Itemised statement totalling $2054.00 across 3 lines.
- Er reported_report_PA-982650.pdf3 pages
Emergency department record: triage acuity 3, chief complaint unspecified abdominal pain.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022236 | 2026-07-01 | Lakeside Medical Group | $185.00 | Approved |
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.