CLM-2026-011564
Canyon Regional Medical Center, Emergency Medicine. Service 2025-12-10 at emergency room (POS 23). Received 2026-01-13.
Member
Resolved through the identity graph
- Member
- Jonathan Weaver
- Member ID
- UHC-19398-18
- Date of birth
- 1979-02-25
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-406568
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-7893
- Coverage period
- 2023-05-01 to present
- Deductible
- $799.13 of $3,500.0023%
- Out-of-pocket maximum
- $6,049.75 of $14,000.0043%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 7874072318
- Network
- In network
- Rendering NPI
- 7874072318
- Location
- Tampa, FL · TIN 53-7384078
- 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 | $240.00 | $132.00 | $132.00 | $0.00 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 2 | $159.00 | $87.45 | $0.00 | $87.45 | Paid |
| 3 | 99284 rev 0450 | Emergency department visit, high severity | 25 | 1 | 1 | $1,122.00 | $617.10 | $0.00 | $617.10 | Paid |
| Totals | $1,521.00 | $836.55 | $132.00 | $704.55 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. R55 Syncope and collapse
- 3. R07.9 Chest pain, unspecified
- Patient account
- PA-571939
- 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-004030 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-10: SELECT-EPO (EPO), effective 2023-05-01. | |
| Timely filing | Pass | Received 34 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 Canyon Regional Medical Center (7874072318). | |
| 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: Canyon Regional Medical Center2025-12-10 18:00
Follow-up for pneumonia, unspecified organism. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-571939.pdf6 pages
Itemised statement totalling $1521.00 across 3 lines.
- Er reported_report_PA-571939.pdf4 pages
Emergency department record: triage acuity 3, 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 engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030412 | 2026-09-10 | Cornerstone Reference Lab | $50.00 | 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.