CLM-2026-004391
Pinecrest Regional Medical Center, Emergency Medicine. Service 2026-08-30 at emergency room (POS 23). Received 2026-09-10.
Member
Resolved through the identity graph
- Member
- Larry Black
- Member ID
- UHC-17622-95
- Date of birth
- 1961-03-15
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-409920
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6853
- Coverage period
- 2023-05-01 to present
- Deductible
- $189.80 of $1,500.0013%
- Out-of-pocket maximum
- $267.16 of $3,000.009%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 1000861728
- Network
- Out of network
- Rendering NPI
- 1000861728
- Location
- Austin, TX · TIN 41-0807117
- 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 | $2,924.00 | $1,315.80 | $150.00 | $1,165.80 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 2 | $191.00 | $85.95 | $0.00 | $85.95 | Paid |
| Totals | $3,115.00 | $1,401.75 | $150.00 | $1,251.75 | ||||||
- 1. R55 Syncope and collapseprincipal
- 2. J18.9 Pneumonia, unspecified organism
- Patient account
- PA-895639
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-009028 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-30: CHOICE-PLUS-PPO (PPO), effective 2023-05-01. | |
| Timely filing | Pass | Received 11 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Center2026-08-30 14:11
Established patient presents with syncope and collapse; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-895639.pdf8 pages
Itemised statement totalling $3115.00 across 2 lines.
- Er reported_report_PA-895639.pdf2 pages
Emergency department record: triage acuity 4, 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 engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
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.