CLM-2026-007255
Pinecrest Regional Medical Center, Emergency Medicine. Service 2026-08-20 at emergency room (POS 23). Received 2026-09-16.
Member
Resolved through the identity graph
- Member
- Marilyn Long
- Member ID
- UHC-18585-05
- Date of birth
- 1982-08-17
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-401264
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-1168
- Coverage period
- 2022-03-01 to 2026-06-21
- Deductible
- $315.74 of $1,000.0032%
- Out-of-pocket maximum
- $1,383.11 of $4,000.0035%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 2061946325
- Network
- In network
- Rendering NPI
- 2061946325
- Location
- Denver, CO · TIN 60-4146079
- 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 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $228.00 | $125.40 | — | — | DeniedCO27 |
| Totals | $228.00 | $125.40 | — | — | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. R10.9 Unspecified abdominal pain
- 3. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- Patient account
- PA-756802
- Frequency code
- 1 (original)
- Accident
- Yes
- 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-025851 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-20 is after coverage terminated on 2026-06-21. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 27 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 Pinecrest Regional Medical Center (2061946325). | |
| 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 Center2026-08-20 14:52
Follow-up for pneumonia, unspecified organism. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-16 03:47
Attachments
Documents received with the claim
- Itemized billitemized_PA-756802.pdf8 pages
Itemised statement totalling $228.00 across 1 line.
- Er reported_report_PA-756802.pdf4 pages
Emergency department record: triage acuity 3, chief complaint pneumonia, unspecified organism.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-20 is after coverage terminated on 2026-06-21.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-003976 | 2026-08-29 | Desert Primary Care Associates | $237.00 | Denied |
| CLM-2026-018000 | 2026-03-12 | Unity Digestive Health Center | $321.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.