CLM-2026-003339
Pinecrest Regional Medical Center, Emergency Medicine. Service 2026-09-21 at emergency room (POS 23). Received 2026-10-03.
Member
Resolved through the identity graph
- Member
- Noah Garrett
- Member ID
- UHC-99638-91
- Date of birth
- 1984-06-17
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-414459
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group NULL
- Coverage period
- 2024-10-01 to present
- Deductible
- $311.41 of $2,500.0012%
- Out-of-pocket maximum
- $4,176.42 of $10,000.0042%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 2061946325
- Network
- In network
- Rendering NPI
- 2061946325
- Location
- Denver, CO · TIN 60-4146079
- 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 | $192.00 | $105.60 | $105.60 | $0.00 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $241.00 | $132.55 | $0.00 | $132.55 | Paid |
| 3 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,626.00 | $894.30 | $0.00 | $894.30 | Paid |
| Totals | $2,059.00 | $1,132.45 | $105.60 | $1,026.85 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-371473
- 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-003769 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-09-21: N/A (PPO), effective 2024-10-01. | |
| Timely filing | Pass | Received 12 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 Pinecrest Regional Medical Center (2061946325). | |
| 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: Pinecrest Regional Medical Center2026-09-21 15:07
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-371473.pdf9 pages
Itemised statement totalling $2059.00 across 3 lines.
- Er reported_report_PA-371473.pdf6 pages
Emergency department record: triage acuity 3, chief complaint chest pain, unspecified.
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-2026-027369 | 2026-03-18 | Sunrise Internal Medicine Associates | $325.00 | Approved |
| CLM-2026-033295 | 2025-12-11 | Unity Imaging Center | $599.00 | 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.