CLM-2026-004765
Pinecrest Regional Medical Center, Emergency Medicine. Service 2026-07-15 at emergency room (POS 23). Received 2026-08-13.
Member
Resolved through the identity graph
- Member
- Gregory James
- Member ID
- UHC-64701-90
- Date of birth
- 1971-03-22
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-419332
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-7365
- Coverage period
- 2022-01-01 to present
- Deductible
- $515.52 of $3,500.0015%
- Out-of-pocket maximum
- $45.19 of $7,000.001%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 5 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 | $236.00 | $129.80 | $129.80 | $0.00 | Paid |
| 2 | 99284 rev 0450 | Emergency department visit, high severity | 25 | 1 | 1 | $1,400.00 | $770.00 | $0.00 | $770.00 | Paid |
| Totals | $1,636.00 | $899.80 | $129.80 | $770.00 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- Patient account
- PA-833872
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-009446 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-15: MEDICARE-ADV-B (MA), effective 2022-01-01. | |
| Timely filing | Pass | Received 29 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 Center2026-07-15 15:55
Patient seen for pneumonia, unspecified organism.
Attachments
Documents received with the claim
- Itemized billitemized_PA-833872.pdf4 pages
Itemised statement totalling $1636.00 across 2 lines.
- Er reported_report_PA-833872.pdf3 pages
Emergency department record: triage acuity 3, chief complaint pneumonia, unspecified organism.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016662 | 2026-06-17 | Riverside Regional Medical Center | $1,319.00 | Approved |
| CLM-2026-019466 | 2026-06-16 | Lakeside Dermatology Clinic | $187.00 | Approved |
| CLM-2026-019615 | 2025-12-25 | Sunrise Dermatology Clinic | $880.00 | 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.