CLM-2026-010525
Mesa Regional Medical Center, Emergency Medicine. Service 2026-02-10 at emergency room (POS 23). Received 2026-03-15.
Member
Resolved through the identity graph
- Member
- Debra Elliott
- Member ID
- UHC-39687-17
- Date of birth
- 1978-03-13
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-416849
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-9887
- Coverage period
- 2023-06-01 to present
- Deductible
- $145.78 of $500.0029%
- Out-of-pocket maximum
- $546.42 of $1,500.0036%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 15 of 20 used
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 | $1,304.00 | $586.80 | $150.00 | $436.80 | Paid |
| Totals | $1,304.00 | $586.80 | $150.00 | $436.80 | ||||||
- 1. R55 Syncope and collapseprincipal
- 2. J18.9 Pneumonia, unspecified organism
- 3. R10.9 Unspecified abdominal pain
- Patient account
- PA-554904
- 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-006244 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-02-10: MEDICARE-ADV-A (MA), effective 2023-06-01. | |
| 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: Mesa Regional Medical Center2026-02-10 10:57
Established patient presents with syncope and collapse; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-554904.pdf9 pages
Itemised statement totalling $1304.00 across 1 line.
- Er reported_report_PA-554904.pdf3 pages
Emergency department record: triage acuity 3, 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 12:44Provider 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-2026-010366 | 2026-07-27 | Meadow Family Practice | $246.00 | Approved |
| CLM-2026-016290 | 2026-01-06 | Northgate Internal Medicine Associates | $44.00 | 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.