CLM-2026-005885
Riverside Community Hospital, Emergency Medicine. Service 2026-05-25 at emergency room (POS 23). Received 2026-06-05.
Member
Resolved through the identity graph
- Member
- Jacob Evans
- Member ID
- UHC-47768-24
- Date of birth
- 1966-12-02
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-412300
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-3724
- Coverage period
- 2022-11-01 to present
- Deductible
- $2,793.13 of $3,500.0080%
- Out-of-pocket maximum
- $831.46 of $7,000.0012%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 18 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 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,612.00 | $886.60 | — | — | Review |
| 2 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $3,040.00 | $1,672.00 | — | — | Review |
| Totals | $4,652.00 | $2,558.60 | — | — | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- Patient account
- PA-604184
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-012675 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-25: MEDICARE-ADV-B (MA), effective 2022-11-01. | |
| Timely filing | Pass | Received 11 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 | Review | CO16 | Documentation incomplete: “Patient seen for pneumonia, unspecified organism. Note dictated; signature pending.”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Riverside Community Hospital2026-05-25 10:40
Patient seen for pneumonia, unspecified organism. Note dictated; signature pending.
- SystemSystem: Claims system2026-06-05 01:18
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
- Itemized billitemized_PA-604184.pdf9 pages
Itemised statement totalling $4652.00 across 2 lines.
- Er reported_report_PA-604184.pdf6 pages
Emergency department record: triage acuity 2, chief complaint pneumonia, unspecified organism.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Patient seen for pneumonia, unspecified organism. Note dictated; signature pending.”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025510 | 2026-01-28 | Northgate Clinical Laboratories | $165.00 | 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
Development letter outstanding.