CLM-2026-010899
Riverside Regional Medical Center, Emergency Medicine. Service 2025-12-18 at emergency room (POS 23). Received 2026-01-19.
Member
Resolved through the identity graph
- Member
- Mary Mason
- Member ID
- UHC-32557-02
- Date of birth
- 1942-05-25
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-432199
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1608
- Coverage period
- 2024-02-01 to present
- Deductible
- $2,051.75 of $2,500.0082%
- Out-of-pocket maximum
- $1,964.98 of $10,000.0020%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 16 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $209.00 | $94.05 | $94.05 | $0.00 | Paid |
| Totals | $209.00 | $94.05 | $94.05 | $0.00 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. R10.9 Unspecified abdominal pain
- 3. R07.9 Chest pain, unspecified
- Patient account
- PA-363527
- 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-005656 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-18: CHOICE-PLUS-PPO (PPO), effective 2024-02-01. | |
| Timely filing | Pass | Received 32 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 Center2025-12-18 09:11
Patient seen for pneumonia, unspecified organism.
Attachments
Documents received with the claim
- Itemized billitemized_PA-363527.pdf4 pages
Itemised statement totalling $209.00 across 1 line.
- Er reported_report_PA-363527.pdf3 pages
Emergency department record: triage acuity 4, 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 engineApproved2026-10-22 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-2026-006883 | 2026-03-25 | Meadow Primary Care Associates | $310.00 | Needs review |
| CLM-2026-006882 | 2026-03-25 | Meadow Primary Care Associates | $310.00 | Approved |
| CLM-2026-018412 | 2026-02-25 | Pinecrest Physical Therapy | $124.00 | Approved |
| CLM-2026-018631 | 2025-12-16 | Harbor Diagnostic Imaging | $2,495.00 | Approved |
| CLM-2026-017217 | 2026-01-09 | Riverside Medical Group | $369.00 | 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.