CLM-2026-011533
Desert Regional Medical Center, Emergency Medicine. Service 2026-02-17 at emergency room (POS 23). Received 2026-03-27.
Member
Resolved through the identity graph
- Member
- Gabriel Robertson
- Member ID
- UHC-65311-64
- Date of birth
- 1946-05-09
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-401402
- Relationship
- Spouse, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7294
- Coverage period
- 2023-02-01 to present
- Deductible
- $379.68 of $1,500.0025%
- Out-of-pocket maximum
- $300.42 of $4,500.007%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 7 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 / REF847434
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 | $1,061.00 | $583.55 | $350.00 | $233.55 | Paid |
| Totals | $1,061.00 | $583.55 | $350.00 | $233.55 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-866265
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-001760 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-02-17: NAVIGATE-HMO (HMO), effective 2023-02-01. | |
| Timely filing | Pass | Received 38 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 Center2026-02-17 14:14
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-866265.pdf4 pages
Itemised statement totalling $1061.00 across 1 line.
- Er reported_report_PA-866265.pdf6 pages
Emergency department record: triage acuity 3, chief complaint unspecified abdominal pain.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-034460 | 2026-05-02 | Riverside Internal Medicine Associates | $293.00 | Denied |
| CLM-2026-034459 | 2026-05-02 | Heritage Medical Group | $293.00 | Approved |
| CLM-2026-021608 | 2026-04-28 | Valley Imaging Center | $3,807.00 | Needs review |
| CLM-2026-003253 | 2025-12-25 | Desert Internal Medicine Associates | $2,210.00 | Needs review |
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.