CLM-2026-002141
Cornerstone Regional Medical Center, Emergency Medicine. Service 2026-02-25 at emergency room (POS 23). Received 2026-03-04.
Member
Resolved through the identity graph
- Member
- Ronald Jimenez
- Member ID
- UHC-03548-71
- Date of birth
- 1942-10-25
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-429301
- Relationship
- Spouse, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-4268
- Coverage period
- 2025-02-01 to present
- Deductible
- $1,386.64 of $3,500.0040%
- Out-of-pocket maximum
- $1,020.23 of $7,000.0015%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- 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 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $178.00 | $97.90 | $97.90 | $0.00 | Paid |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 2 | $681.00 | $374.55 | $0.00 | $374.55 | Paid |
| 3 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1,2 | $1,434.00 | $788.70 | $0.00 | $788.70 | Paid |
| Totals | $2,293.00 | $1,261.15 | $97.90 | $1,163.25 | ||||||
- 1. R55 Syncope and collapseprincipal
- 2. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- 3. R07.9 Chest pain, unspecified
- Patient account
- PA-840926
- Frequency code
- 1 (original)
- Accident
- Yes
- 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-017341 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-25: NULL (PPO), effective 2025-02-01. | |
| Timely filing | Pass | Received 7 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 Center2026-02-25 11:17
Follow-up for syncope and collapse. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-840926.pdf5 pages
Itemised statement totalling $2293.00 across 3 lines.
- Er reported_report_PA-840926.pdf5 pages
Emergency department record: triage acuity 2, 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-013066 | 2026-04-13 | Meadow Regional Medical Center | $4,603.00 | 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.