CLM-2026-003770
Pinecrest Regional Medical Center, Emergency Medicine. Service 2026-01-08 at emergency room (POS 23). Received 2026-01-27.
Member
Resolved through the identity graph
- Member
- Montgomery Edward
- Member ID
- UHC-32912-54
- Date of birth
- 1953-05-27
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-419508
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-2162
- Coverage period
- 2024-02-01 to present
- Deductible
- $1,030.86 of $1,500.0069%
- Out-of-pocket maximum
- $1,561.23 of $4,500.0035%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 2 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 | $155.00 | $85.25 | $85.25 | $0.00 | Paid |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $991.00 | $545.05 | $0.00 | $545.05 | Paid |
| Totals | $1,146.00 | $630.30 | $85.25 | $545.05 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. J18.9 Pneumonia, unspecified organism
- 3. R10.9 Unspecified abdominal pain
- Patient account
- PA-451178
- Frequency code
- 1 (original)
- Accident
- No
- 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-007975 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-08: NULL (PPO), effective 2024-02-01. | |
| Timely filing | Pass | Received 19 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 Center2026-01-08 18:46
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-451178.pdf9 pages
Itemised statement totalling $1146.00 across 2 lines.
- Er reported_report_PA-451178.pdf3 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-2026-005379 | 2026-03-24 | Lakeside Behavioral Health | $178.00 | 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.