CLM-2026-008190
Desert Regional Medical Center, Emergency Medicine. Service 2026-03-13 at emergency room (POS 23). Received 2026-03-20.
Member
Resolved through the identity graph
- Member
- Abigail Hicks
- Member ID
- UHC-60211-80
- Date of birth
- 1970-08-17
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-410123
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-1170
- Coverage period
- 2024-12-01 to 2026-01-22
- Deductible
- $2,173.31 of $2,500.0087%
- Out-of-pocket maximum
- $4,867.61 of $10,000.0049%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 8317237419
- Network
- In network
- Rendering NPI
- 8317237419
- Location
- Austin, TX · TIN 55-6992539
- 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 | $2,327.00 | $1,279.85 | — | — | DeniedCO27 |
| Totals | $2,327.00 | $1,279.85 | — | — | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. R55 Syncope and collapse
- Patient account
- PA-973578
- Frequency code
- 1 (original)
- Accident
- Yes
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-006998 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-03-13 is after coverage terminated on 2026-01-22. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 7 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 Desert Regional Medical Center (8317237419). | |
| 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: Desert Regional Medical Center2026-03-13 09:18
Patient seen for pneumonia, unspecified organism.
- SystemSystem: Claims system2026-03-20 03:38
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-03-20 13:10
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-973578.pdf8 pages
Itemised statement totalling $2327.00 across 1 line.
- Er reported_report_PA-973578.pdf4 pages
Emergency department record: triage acuity 4, chief complaint pneumonia, unspecified organism.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-03-13 is after coverage terminated on 2026-01-22.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007041 | 2026-08-28 | Mesa Diabetes Center | $67.00 | Denied |
| CLM-2026-008129 | 2026-05-24 | Valley Family Practice | $510.00 | Denied |
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.