CLM-2026-001058
Cornerstone Regional Medical Center, Emergency Medicine. Service 2026-08-23 at emergency room (POS 23). Received 2026-09-02.
Member
Resolved through the identity graph
- Member
- Samantha Santos
- Member ID
- UHC-42300-84
- Date of birth
- 2005-03-04
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-412201
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group UNKNOWN
- Coverage period
- 2021-05-01 to present
- Deductible
- $1,208.72 of $3,500.0035%
- Out-of-pocket maximum
- $5,212.37 of $10,500.0050%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 1149569109
- Network
- In network
- Rendering NPI
- 1149569109
- Location
- Nashville, TN · TIN 45-8232836
- 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 | — | 1 | 1 | $1,736.00 | $954.80 | $150.00 | $804.80 | Paid |
| Totals | $1,736.00 | $954.80 | $150.00 | $804.80 | ||||||
- 1. R55 Syncope and collapseprincipal
- Patient account
- PA-208313
- 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-034724 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-23: MEDICARE-ADV-B (MA), effective 2021-05-01. | |
| Timely filing | Pass | Received 10 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 Cornerstone Regional Medical Center (1149569109). | |
| 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: Cornerstone Regional Medical Center2026-08-23 09:33
Follow-up for syncope and collapse. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-208313.pdf7 pages
Itemised statement totalling $1736.00 across 1 line.
- Er reported_report_PA-208313.pdf3 pages
Emergency department record: triage acuity 3, chief complaint syncope and collapse.
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.