CLM-2026-008978
Cornerstone Regional Medical Center, Emergency Medicine. Service 2026-02-04 at emergency room (POS 23). Received 2026-03-16.
Member
Resolved through the identity graph
- Member
- Lucia Padilla
- Member ID
- UHC-90643-40
- Date of birth
- 1998-10-19
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-424079
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6403
- Coverage period
- 2022-09-01 to present
- Deductible
- $2,208.39 of $2,500.0088%
- Out-of-pocket maximum
- $1,756.62 of $7,500.0023%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 1149569109
- Network
- In network
- Rendering NPI
- 1149569109
- Location
- Nashville, TN · TIN 45-8232836
- 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 | $2,028.00 | $1,115.40 | $350.00 | $765.40 | Paid |
| 2 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $163.00 | $89.65 | $0.00 | $89.65 | Paid |
| Totals | $2,191.00 | $1,205.05 | $350.00 | $855.05 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-346685
- 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-020028 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-04: CHOICE-PLUS-PPO (PPO), effective 2022-09-01. | |
| Timely filing | Pass | Received 40 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 Cornerstone Regional Medical Center (1149569109). | |
| 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: Cornerstone Regional Medical Center2026-02-04 12:21
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-346685.pdf2 pages
Itemised statement totalling $2191.00 across 2 lines.
- Er reported_report_PA-346685.pdf6 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-2026-029288 | 2026-03-16 | Northgate Clinical Laboratories | $157.00 | Denied |
| CLM-2026-029287 | 2026-03-16 | Northgate Clinical Laboratories | $157.00 | 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.