CLM-2026-008128
Mesa Regional Medical Center, Emergency Medicine. Service 2025-12-06 at emergency room (POS 23). Received 2026-01-06.
Member
Resolved through the identity graph
- Member
- Gregory Reid
- Member ID
- UHC-65879-07
- Date of birth
- 1943-07-18
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-419105
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-7587
- Coverage period
- 2025-06-01 to present
- Deductible
- $604.12 of $1,000.0060%
- Out-of-pocket maximum
- $361.95 of $3,000.0012%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 3600007819
- Network
- Out of network
- Rendering NPI
- 3600007819
- Location
- Tampa, FL · TIN 90-5702951
- 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 | $1,485.00 | $816.75 | — | — | Review |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1,2 | $1,006.00 | $553.30 | — | — | Review |
| Totals | $2,491.00 | $1,370.05 | — | — | ||||||
- 1. R55 Syncope and collapseprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-627978
- 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-001792 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-12-06: SELECT-EPO (EPO), effective 2025-06-01. | |
| Timely filing | Pass | Received 31 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: Mesa Regional Medical Center2025-12-06 17:12
Follow-up for syncope and collapse. Plan discussed, medications reconciled. Patient presented to the nearest emergency department with acute symptoms; care could not safely be delayed to reach an in-network facility.
- SystemSystem: Claims system2026-01-06 01:53
Out-of-network emergency visit. Emergency services are payable at the in-network level when the prudent-layperson standard is met.
Attachments
Documents received with the claim
- Itemized billitemized_PA-627978.pdf8 pages
Itemised statement totalling $2491.00 across 2 lines.
- Er reported_report_PA-627978.pdf5 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 engineReview2026-10-21 13:43Provider network: Out-of-network emergency visit. Payable at the in-network level if the prudent-layperson standard is met; review the ED record.
- AI recommendationApproved2026-10-21 14:14The claim is for an out-of-network emergency visit, which is payable at the in-network level if the prudent-layperson standard is met. The clinical note [N1] indicates that the patient presented to the nearest emergency department with acute symptoms, and care could not safely be delayed to reach an in-network facility. The claim meets all other adjudication criteria, and the billed amount is within the auto-adjudication ceiling. However, since the claim is billed above $15,000.00, it requires human sign-off.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:14 · cd98bed8
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020792 | 2026-10-07 | Mesa Orthopedic Specialists | $46,944.00 | Needs review |
| CLM-2026-004549 | 2026-04-27 | Lakeside Medical Group | $531.00 | Approved |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
The claim is for an out-of-network emergency visit, which is payable at the in-network level if the prudent-layperson standard is met. The clinical note [N1] indicates that the patient presented to the nearest emergency department with acute symptoms, and care could not safely be delayed to reach an in-network facility. The claim meets all other adjudication criteria, and the billed amount is within the auto-adjudication ceiling. However, since the claim is billed above $15,000.00, it requires human sign-off.
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.