CLM-2026-004859
Pinecrest Regional Medical Center, Emergency Medicine. Service 2026-06-16 at emergency room (POS 23). Received 2026-07-26.
Member
Resolved through the identity graph
- Member
- Roger Luna
- Member ID
- none on golden record
- Date of birth
- 1960-10-11
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-431666
- Relationship
- Child, Miami, FL
Coverage and accumulators
Found by name and date of birth
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7830
- Coverage period
- 2025-09-01 to present
- Deductible
- $2,061.25 of $2,500.0082%
- Out-of-pocket maximum
- $739.07 of $5,000.0015%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 9 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 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $1,037.00 | $466.65 | — | — | Review |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $164.00 | $73.80 | — | — | Review |
| Totals | $1,201.00 | $540.45 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-451272
- Frequency code
- 7 (replacement)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 12 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-030531 (verified, link confidence 1.00). | |
| Eligibility | Note | Active on 2026-06-16: - (PPO), effective 2025-09-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 40 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Replacement claim | Review | REPL | Frequency code 7 replaces CLM-2026-004858; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission |
| 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 Center2026-06-16 12:06
Patient seen for unspecified abdominal pain. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
- SystemSystem: Claims system2026-07-26 02:11
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-07-26 16:25
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-451272.pdf6 pages
Itemised statement totalling $1201.00 across 2 lines.
- Er reported_report_PA-451272.pdf3 pages
Emergency department record: triage acuity 4, chief complaint unspecified abdominal pain.
- Corrected claimcorrected_CLM-2026-004858.pdf1 page
Provider cover letter requesting replacement of CLM-2026-004858.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Eligibility: Active on 2026-06-16: - (PPO), effective 2025-09-01. Coverage found by name and date of birth because the claim carried no usable member ID. Replacement claim: Frequency code 7 replaces CLM-2026-004858; the original must be voided when this adjudicates. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004858 | 2026-06-16 | Pinecrest Regional Medical Center | $1,201.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Replacement claim supersedes the original.