CLM-2026-001188
Canyon Regional Medical Center, Emergency Medicine. Service 2026-04-14 at emergency room (POS 23). Received 2026-05-04.
Member
Resolved through the identity graph
- Member
- Dunna Oliver
- Member ID
- none on golden record
- Date of birth
- 1964-01-19
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-422703
- Relationship
- Child, Seattle, WA
Coverage and accumulators
Eligibility
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 / 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 | $1,906.00 | $1,048.30 | — | — | PendedN30 |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 2 | $638.00 | $350.90 | — | — | PendedN30 |
| Totals | $2,544.00 | $1,399.20 | — | — | ||||||
- 1. R55 Syncope and collapseprincipal
- Patient account
- PA-891454
- Frequency code
- 1 (original)
- Accident
- No
- 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-029089 (provisional, link confidence 1.00). | |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 20 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 Center2026-04-14 15:53
Follow-up for syncope and collapse. Plan discussed, medications reconciled. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-05-04 03:22
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-891454.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
- Itemized billitemized_PA-891454.pdf3 pages
Itemised statement totalling $2544.00 across 2 lines.
- Er reported_report_PA-891454.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 enginePended2026-10-22 12:44Eligibility: No coverage segment found for the member ID on this claim.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Authorisation must be confirmed with UM before payment.