CLM-2026-010120
Canyon Regional Medical Center, Emergency Medicine. Service 2025-11-28 at emergency room (POS 23). Received 2026-01-12.
Member
Resolved through the identity graph
- Member
- Jesse Peterson
- Member ID
- UHC-22892-68
- Date of birth
- 1963-11-24
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-427683
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4256
- Coverage period
- 2021-11-01 to present
- Deductible
- $955.97 of $2,500.0038%
- Out-of-pocket maximum
- $353.98 of $7,500.005%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 15 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 / 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $216.00 | $118.80 | $118.80 | $0.00 | Paid |
| Totals | $216.00 | $118.80 | $118.80 | $0.00 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. R07.9 Chest pain, unspecified
- 3. R55 Syncope and collapse
- Patient account
- PA-718879
- 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-003718 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-11-28: CHOICE-PLUS-PPO (PPO), effective 2021-11-01. | |
| Timely filing | Pass | Received 45 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 Center2025-11-28 13:12
Patient seen for pneumonia, unspecified organism.
Attachments
Documents received with the claim
- Itemized billitemized_PA-718879.pdf2 pages
Itemised statement totalling $216.00 across 1 line.
- Er reported_report_PA-718879.pdf6 pages
Emergency department record: triage acuity 2, chief complaint pneumonia, unspecified organism.
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-2026-020466 | 2026-08-09 | Pinecrest Behavioral Health | $250.00 | Needs review |
| CLM-2026-020465 | 2026-08-09 | Sunrise Behavioral Health | $250.00 | Approved |
| CLM-2026-000055 | 2026-06-21 | Valley Bone and Joint Center | $262.00 | 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.