CLM-2026-007431
Riverside Regional Medical Center, Emergency Medicine. Service 2026-09-15 at emergency room (POS 23). Received 2026-10-07.
Member
Resolved through the identity graph
- Member
- Sean Varrgas
- Member ID
- none on golden record
- Date of birth
- 1992-06-05
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-414009
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by name and date of birth
- Plan
- MEDICARE-ADV-B MA group GRP-1802
- Coverage period
- 2021-05-01 to present
- Deductible
- $28.10 of $500.006%
- Out-of-pocket maximum
- $716.93 of $2,000.0036%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 20 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 / 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 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $3,196.00 | $1,438.20 | $150.00 | $1,288.20 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $137.00 | $61.65 | $0.00 | $61.65 | Paid |
| Totals | $3,333.00 | $1,499.85 | $150.00 | $1,349.85 | ||||||
- 1. R55 Syncope and collapseprincipal
- Patient account
- PA-823521
- 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 | Pass | Attached to MBR-045956 (provisional, link confidence 1.00). | |
| Eligibility | Note | Active on 2026-09-15: MEDICARE-ADV-B (MA), effective 2021-05-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 22 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 | 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: Riverside Regional Medical Center2026-09-15 14:49
Established patient presents with syncope and collapse; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-823521.pdf5 pages
Itemised statement totalling $3333.00 across 2 lines.
- Er reported_report_PA-823521.pdf4 pages
Emergency department record: triage acuity 4, 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 engineApproved2026-10-21 13:43Eligibility: Active on 2026-09-15: MEDICARE-ADV-B (MA), effective 2021-05-01. Coverage found by name and date of birth because the claim carried no usable member ID. 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
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.