CLM-2026-012330
Riverside Community Hospital, Emergency Medicine. Service 2026-04-11 at emergency room (POS 23). Received 2026-05-18.
Member
Resolved through the identity graph
- Member
- Lori Austin
- Member ID
- UHC-45897-76
- Date of birth
- 2003-07-23
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-414236
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2336
- Coverage period
- 2025-07-01 to present
- Deductible
- $268.10 of $500.0054%
- Out-of-pocket maximum
- $690.66 of $1,500.0046%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 1928747868
- Network
- In network
- Rendering NPI
- 1928747868
- Location
- Mesa, AZ · TIN 30-6800456
- 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 | $246.00 | $135.30 | — | — | Review |
| Totals | $246.00 | $135.30 | — | — | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-287782
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-007093 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-11: NULL (PPO), effective 2025-07-01. | |
| Timely filing | Pass | Received 37 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 Riverside Community Hospital (1928747868). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Established patient presents with pneumonia, unspecified organism; symptoms reviewed and v”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Riverside Community Hospital2026-04-11 09:29
Established patient presents with pneumonia, unspecified organism; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-05-18 04:21
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
- Itemized billitemized_PA-287782.pdf9 pages
Itemised statement totalling $246.00 across 1 line.
- Er reported_report_PA-287782.pdf6 pages
Emergency department record: triage acuity 4, chief complaint pneumonia, unspecified organism.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Established patient presents with pneumonia, unspecified organism; symptoms reviewed and v”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012739 | 2026-08-23 | Evergreen Diagnostic Imaging | $4,002.00 | Approved |
| CLM-2026-000806 | 2026-09-23 | Mesa Imaging Center | $2,712.00 | Needs review |
| CLM-2026-012830 | 2026-01-17 | Lakeside Reference Lab | $119.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.