CLM-2026-003655
Canyon Regional Medical Center, Emergency Medicine. Service 2026-06-01 at emergency room (POS 23). Received 2026-07-12.
Member
Resolved through the identity graph
- Member
- Elijah Peters
- Member ID
- UHC-48945-36
- Date of birth
- 1908-03-01
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-408802
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group UNKNOWN
- Coverage period
- 2022-11-01 to 2026-01-14
- Deductible
- $2,312.56 of $3,500.0066%
- Out-of-pocket maximum
- $3,275.48 of $10,500.0031%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
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 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $617.00 | $339.35 | — | — | DeniedCO27 |
| Totals | $617.00 | $339.35 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. R55 Syncope and collapse
- Patient account
- PA-730935
- 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-038145 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-01 is after coverage terminated on 2026-01-14. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 41 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 Center2026-06-01 18:09
Patient seen for unspecified abdominal pain.
- SystemSystem: Claims system2026-07-12 03:05
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-07-12 16:18
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-730935.pdf9 pages
Itemised statement totalling $617.00 across 1 line.
- Er reported_report_PA-730935.pdf2 pages
Emergency department record: triage acuity 2, chief complaint unspecified abdominal pain.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-06-01 is after coverage terminated on 2026-01-14.
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.