CLM-2026-001140
Cornerstone Regional Medical Center, Emergency Medicine. Service 2026-06-11 at emergency room (POS 23). Received 2026-07-04.
Member
Resolved through the identity graph
- Member
- Maria Medina
- Member ID
- UHC-20019-45
- Date of birth
- 1938-06-17
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-418182
- Relationship
- Spouse, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4560
- Coverage period
- 2021-01-01 to 2026-03-04
- Deductible
- $860.16 of $2,500.0034%
- Out-of-pocket maximum
- $3,150.11 of $7,500.0042%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 9 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 | $3,117.00 | $1,714.35 | — | — | DeniedCO27 |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $902.00 | $496.10 | — | — | DeniedCO27 |
| Totals | $4,019.00 | $2,210.45 | — | — | ||||||
- 1. R55 Syncope and collapseprincipal
- 2. J18.9 Pneumonia, unspecified organism
- 3. R07.9 Chest pain, unspecified
- Patient account
- PA-590484
- Frequency code
- 1 (original)
- Accident
- Yes
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-021422 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-11 is after coverage terminated on 2026-03-04. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 23 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 Center2026-06-11 18:58
Established patient presents with syncope and collapse; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-04 00:50
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-07-04 13:15
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-590484.pdf5 pages
Itemised statement totalling $4019.00 across 2 lines.
- Er reported_report_PA-590484.pdf6 pages
Emergency department record: triage acuity 2, chief complaint syncope and collapse.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-06-11 is after coverage terminated on 2026-03-04.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.