CLM-2026-010345
Desert Regional Medical Center, Emergency Medicine. Service 2026-02-10 at emergency room (POS 23). Received 2026-03-03.
Member
Resolved through the identity graph
- Member
- Julie Reynolds
- Member ID
- UHC-23496-10
- Date of birth
- 2003-09-10
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-409316
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-4940
- Coverage period
- 2024-09-01 to 2026-02-02
- Deductible
- $78.50 of $500.0016%
- Out-of-pocket maximum
- $579.73 of $2,000.0029%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 8317237419
- Network
- In network
- Rendering NPI
- 8317237419
- Location
- Austin, TX · TIN 55-6992539
- 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 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $608.00 | $334.40 | — | — | DeniedCO27 |
| 2 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 2 | $1,041.00 | $572.55 | — | — | DeniedCO27 |
| 3 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $222.00 | $122.10 | — | — | DeniedCO27 |
| Totals | $1,871.00 | $1,029.05 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. J18.9 Pneumonia, unspecified organism
- Patient account
- PA-770417
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-013104 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-02-10 is after coverage terminated on 2026-02-02. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 21 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 Desert Regional Medical Center (8317237419). | |
| 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: Desert Regional Medical Center2026-02-10 11:32
Patient seen for chest pain, unspecified.
- SystemSystem: Claims system2026-03-03 01:12
Attachments
Documents received with the claim
- Itemized billitemized_PA-770417.pdf2 pages
Itemised statement totalling $1871.00 across 3 lines.
- Er reported_report_PA-770417.pdf5 pages
Emergency department record: triage acuity 4, chief complaint chest pain, unspecified.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-02-10 is after coverage terminated on 2026-02-02.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-013514 | 2026-08-12 | Canyon Medical Group | $206.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.