CLM-2026-010180
Riverside Regional Medical Center, Emergency Medicine. Service 2026-05-24 at emergency room (POS 23). Received 2026-06-26.
Member
Resolved through the identity graph
- Member
- Donna Hunter
- Member ID
- UHC-21504-45
- Date of birth
- 1992-05-20
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-400037
- Relationship
- Child
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6325
- Coverage period
- 2023-04-01 to present
- Deductible
- $528.02 of $3,500.0015%
- Out-of-pocket maximum
- $1,884.23 of $7,000.0027%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 5185579187
- Network
- Out of network
- Rendering NPI
- 5185579187
- Location
- Tempe, AZ · TIN 24-5730797
- 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 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $157.00 | $70.65 | — | — | PendedIDQ |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 2 | $179.00 | $80.55 | — | — | PendedIDQ |
| Totals | $336.00 | $151.20 | — | — | ||||||
- 1. S93.401A Sprain of unspecified ligament of right ankle, initial encounterprincipal
- Patient account
- PA-381415
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-003425; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-05-24: - (PPO), effective 2023-04-01. | |
| Timely filing | Pass | Received 33 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 | 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: Riverside Regional Medical Center2026-05-24 12:42
Established patient presents with sprain of unspecified ligament of right ankle, initial encounter; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-381415.pdf9 pages
Itemised statement totalling $336.00 across 2 lines.
- Er reported_report_PA-381415.pdf4 pages
Emergency department record: triage acuity 4, chief complaint sprain of unspecified ligament of right ankle, initial encounter.
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-003425; payment withheld until the identity is confirmed. 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
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
Clean claim, priced at contract rate.