CLM-2026-004842
Canyon Regional Medical Center, Emergency Medicine. Service 2026-04-28 at emergency room (POS 23). Received 2026-05-07.
Member
Resolved through the identity graph
- Member
- Mariana Lee
- Member ID
- UHC-21542-39
- Date of birth
- 1972-01-02
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-413503
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-2412
- Coverage period
- 2025-09-01 to present
- Deductible
- $1,995.54 of $2,500.0080%
- Out-of-pocket maximum
- $1,135.63 of $5,000.0023%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 10 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 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,671.00 | $919.05 | $250.00 | $669.05 | Paid |
| 2 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $2,666.00 | $1,466.30 | $0.00 | $1,466.30 | Paid |
| 3 | 71046 rev 0320 | Chest X-ray, two views | 25 | 1 | 1,2 | $231.00 | $127.05 | $0.00 | $127.05 | Paid |
| Totals | $4,568.00 | $2,512.40 | $250.00 | $2,262.40 | ||||||
- 1. R55 Syncope and collapseprincipal
- 2. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- 3. R07.9 Chest pain, unspecified
- Patient account
- PA-213796
- 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-001397 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-28: MEDICARE-ADV-B (MA), effective 2025-09-01. | |
| Timely filing | Pass | Received 9 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 Center2026-04-28 09:17
Patient seen for syncope and collapse.
Attachments
Documents received with the claim
- Itemized billitemized_PA-213796.pdf6 pages
Itemised statement totalling $4568.00 across 3 lines.
- Er reported_report_PA-213796.pdf6 pages
Emergency department record: triage acuity 3, 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.