CLM-2026-000935
Canyon Regional Medical Center, Emergency Medicine. Service 2026-06-19 at emergency room (POS 23). Received 2026-07-08.
Member
Resolved through the identity graph
- Member
- George Austin
- Member ID
- UHC-22482-04
- Date of birth
- 1938-09-20
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-425026
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-1677
- Coverage period
- 2022-03-01 to present
- Deductible
- $89.81 of $500.0018%
- Out-of-pocket maximum
- $493.29 of $1,000.0049%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 7874072318
- Network
- In network
- Rendering NPI
- 7874072318
- Location
- Tampa, FL · TIN 53-7384078
- Authorisation / referral
- none / REF276410
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 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,231.00 | $677.05 | $350.00 | $327.05 | Paid |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | 25 | 1 | 2 | $934.00 | $513.70 | $0.00 | $513.70 | Paid |
| 3 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 2 | $210.00 | $115.50 | $0.00 | $115.50 | Paid |
| Totals | $2,375.00 | $1,306.25 | $350.00 | $956.25 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-582505
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-003104 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-19: NAVIGATE-HMO (HMO), effective 2022-03-01. | |
| 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 Canyon Regional Medical Center (7874072318). | |
| 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: Canyon Regional Medical Center2026-06-19 17:18
Follow-up for pneumonia, unspecified organism. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-582505.pdf2 pages
Itemised statement totalling $2375.00 across 3 lines.
- Er reported_report_PA-582505.pdf6 pages
Emergency department record: triage acuity 2, chief complaint pneumonia, unspecified organism.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
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.