CLM-2026-008889
Desert Regional Medical Center, Emergency Medicine. Service 2025-12-07 at emergency room (POS 23). Received 2026-01-02.
Member
Resolved through the identity graph
- Member
- Sophia Lawrence
- Member ID
- UHC-54923-39
- Date of birth
- 1989-05-04
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-423247
- Relationship
- Spouse, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5553
- Coverage period
- 2022-04-01 to present
- Deductible
- $14.91 of $1,000.001%
- Out-of-pocket maximum
- $75.86 of $3,000.003%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 0 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 / REF890420
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 | $146.00 | $80.30 | $80.30 | $0.00 | Paid |
| Totals | $146.00 | $80.30 | $80.30 | $0.00 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-370808
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000360 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-07: NAVIGATE-HMO (HMO), effective 2022-04-01. | |
| Timely filing | Pass | Received 26 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 Center2025-12-07 16:20
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-370808.pdf3 pages
Itemised statement totalling $146.00 across 1 line.
- Er reported_report_PA-370808.pdf5 pages
Emergency department record: triage acuity 3, chief complaint chest pain, unspecified.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005927 | 2026-08-31 | Meadow Family Practice | $666.00 | Approved |
| CLM-2026-018090 | 2026-08-23 | Lakeside Dermatology Clinic | $443.00 | Approved |
| CLM-2026-003397 | 2026-03-12 | Cornerstone Regional Medical Center | $1,439.00 | Approved |
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.