CLM-2026-009261
Canyon Regional Medical Center, Emergency Medicine. Service 2026-04-20 at emergency room (POS 23). Received 2026-05-31.
Member
Resolved through the identity graph
- Member
- Raymond Carlson
- Member ID
- UHC-58887-83
- Date of birth
- 1975-09-18
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-430341
- Relationship
- Spouse, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-2044
- Coverage period
- 2022-04-01 to present
- Deductible
- $495.84 of $1,000.0050%
- Out-of-pocket maximum
- $1,853.58 of $4,000.0046%
- Copays
- office $30.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 7874072318
- Network
- In network
- Rendering NPI
- 7874072318
- Location
- Tampa, FL · TIN 53-7384078
- Authorisation / referral
- none / REF531733
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 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $1,055.00 | $580.25 | $350.00 | $230.25 | Paid |
| 2 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $253.00 | $139.15 | $0.00 | $139.15 | Paid |
| Totals | $1,308.00 | $719.40 | $350.00 | $369.40 | ||||||
- 1. R55 Syncope and collapseprincipal
- 2. J18.9 Pneumonia, unspecified organism
- 3. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- Patient account
- PA-844799
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-016518 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-20: CORE-HMO (HMO), effective 2022-04-01. | |
| Timely filing | Pass | Received 41 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 Canyon Regional Medical Center (7874072318). | |
| 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: Canyon Regional Medical Center2026-04-20 17:43
Follow-up for syncope and collapse. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-844799.pdf7 pages
Itemised statement totalling $1308.00 across 2 lines.
- Er reported_report_PA-844799.pdf2 pages
Emergency department record: triage acuity 2, 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 engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-006749 | 2026-08-18 | Northgate Clinical Laboratories | $87.00 | Denied |
| CLM-2026-006748 | 2026-08-18 | Northgate Clinical Laboratories | $87.00 | 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.