CLM-2026-005361
Riverside Regional Medical Center, Emergency Medicine. Service 2026-09-19 at emergency room (POS 23). Received 2026-09-22.
Member
Resolved through the identity graph
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-0971
- Coverage period
- 2023-08-01 to present
- Deductible
- $148.55 of $1,500.0010%
- Out-of-pocket maximum
- $897.39 of $4,500.0020%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 5185579187
- Network
- Out of network
- Rendering NPI
- 5185579187
- Location
- Tempe, AZ · TIN 24-5730797
- Authorisation / referral
- none / REF839613
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 | $3,094.00 | $1,701.70 | — | — | PendedCO16 |
| Totals | $3,094.00 | $1,701.70 | — | — | ||||||
- 1. R55 Syncope and collapseprincipal
- Patient account
- PA-936605
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | CO16 | Claim record is not attached to a resolved identity. Claim lacks information needed for adjudication |
| Eligibility | Pass | Active on 2026-09-19: CORE-HMO (HMO), effective 2023-08-01. | |
| Timely filing | Pass | Received 3 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 | Review | NET | Out-of-network emergency visit. Payable at the in-network level if the prudent-layperson standard is met; review the ED record. Out-of-network provider |
| 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 Regional Medical Center2026-09-19 09:37
Patient seen for syncope and collapse. Patient presented to the nearest emergency department with acute symptoms; care could not safely be delayed to reach an in-network facility.
- SystemSystem: Claims system2026-09-22 05:02
Out-of-network emergency visit. Emergency services are payable at the in-network level when the prudent-layperson standard is met.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-09-22 14:31
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-936605.pdf5 pages
Itemised statement totalling $3094.00 across 1 line.
- Er reported_report_PA-936605.pdf6 pages
Emergency department record: triage acuity 2, chief complaint syncope and collapse.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Claim record is not attached to a resolved identity. Provider network: Out-of-network emergency visit. Payable at the in-network level if the prudent-layperson standard is met; review the ED record.
Other claims for this member
Same resolved identity
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
Emergency: payable at in-network level.