CLM-2026-004837
Riverside Community Hospital, Emergency Medicine. Service 2026-05-23 at emergency room (POS 23). Received 2026-06-06.
Member
Resolved through the identity graph
- Member
- Scott Estrada
- Member ID
- UHC-21355-47
- Date of birth
- 1963-11-20
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-425525
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-2676
- Coverage period
- 2023-01-01 to present
- Deductible
- $794.50 of $1,000.0079%
- Out-of-pocket maximum
- $1,327.58 of $4,000.0033%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 1928747868
- Network
- In network
- Rendering NPI
- 1928747868
- Location
- Mesa, AZ · TIN 30-6800456
- 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $196.00 | $107.80 | $107.80 | $0.00 | Paid |
| 2 | 99284 rev 0450 | Emergency department visit, high severity | 25 | 1 | 1 | $1,539.00 | $846.45 | $0.00 | $846.45 | Paid |
| 3 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $141.00 | $77.55 | $0.00 | $77.55 | Paid |
| Totals | $1,876.00 | $1,031.80 | $107.80 | $924.00 | ||||||
- 1. R55 Syncope and collapseprincipal
- Patient account
- PA-317103
- 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-033920 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-05-23: SELECT-EPO (EPO), effective 2023-01-01. | |
| Timely filing | Pass | Received 14 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 Riverside Community Hospital (1928747868). | |
| 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: Riverside Community Hospital2026-05-23 15:01
Patient seen for syncope and collapse.
Attachments
Documents received with the claim
- Itemized billitemized_PA-317103.pdf3 pages
Itemised statement totalling $1876.00 across 3 lines.
- Er reported_report_PA-317103.pdf3 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 engineApproved2026-10-22 12:44Clean claim.
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.