CLM-2026-010133
Mesa Regional Medical Center, Emergency Medicine. Service 2026-09-01 at emergency room (POS 23). Received 2026-10-03.
Member
Resolved through the identity graph
- Member
- Pamela Harvey
- Member ID
- none on golden record
- Date of birth
- 1942-08-04
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-404357
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Eligibility
Provider
Billing and rendering
- Billing provider
- Mesa Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 3600007819
- Network
- Out of network
- Rendering NPI
- 3600007819
- Location
- Tampa, FL · TIN 90-5702951
- 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 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,250.00 | $562.50 | — | — | PendedIDQ |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $614.00 | $276.30 | — | — | PendedIDQ |
| 3 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $1,895.00 | $852.75 | — | — | PendedIDQ |
| Totals | $3,759.00 | $1,691.55 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-836892
- Frequency code
- 7 (replacement)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 12 checks, 4 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-002693; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 32 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Replacement claim | Review | REPL | Frequency code 7 replaces CLM-2026-010132; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Mesa Regional Medical Center2026-09-01 10:04
Patient seen for unspecified abdominal pain. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
- SystemSystem: Claims system2026-10-03 04:22
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
Attachments
Documents received with the claim
- Itemized billitemized_PA-836892.pdf7 pages
Itemised statement totalling $3759.00 across 3 lines.
- Er reported_report_PA-836892.pdf5 pages
Emergency department record: triage acuity 4, chief complaint unspecified abdominal pain.
- Corrected claimcorrected_CLM-2026-010132.pdf1 page
Provider cover letter requesting replacement of CLM-2026-010132.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-002693; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim. Replacement claim: Frequency code 7 replaces CLM-2026-010132; the original must be voided when this adjudicates. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010132 | 2026-09-01 | Mesa Regional Medical Center | $3,759.00 | Pended |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Replacement claim supersedes the original.