CLM-2026-013531
Desert Regional Medical Center, Emergency Medicine. Service 2026-06-03 at emergency room (POS 23). Received 2026-07-05.
Member
Resolved through the identity graph
- Member
- Jerry Romero
- Member ID
- UHC-98312-99
- Date of birth
- 1964-03-24
- Identity
- Verified7 records, confidence 0.97
- Claim record
- CLMCLM-412843
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-5539
- Coverage period
- 2023-02-01 to present
- Deductible
- $2,569.72 of $3,500.0073%
- Out-of-pocket maximum
- $3,838.54 of $10,500.0037%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 18 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 / REF505909
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 | 59 | 1 | 1 | $166.00 | $91.30 | — | — | Review |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | 59 | 1 | 1,2 | $785.00 | $431.75 | — | — | Review |
| Totals | $951.00 | $523.05 | — | — | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- Patient account
- PA-812557
- Frequency code
- 1 (original)
- Accident
- Yes
- 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-023099 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-06-03: CORE-HMO (HMO), effective 2023-02-01. | |
| 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 | Pass | In-network provider Desert Regional Medical Center (8317237419). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Center2026-06-03 13:57
Patient seen for pneumonia, unspecified organism. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
- SystemSystem: Claims system2026-07-05 06:27
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Itemized billitemized_PA-812557.pdf8 pages
Itemised statement totalling $951.00 across 2 lines.
- Medical recordrecords_PA-812557.pdf9 pages
Operative note describing procedures at two distinct anatomical sites.
- Er reported_report_PA-812557.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 13:43Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016075 | 2026-06-03 | Evergreen Orthopedic Specialists | $5,950.00 | Approved |
| CLM-2026-017055 | 2026-02-27 | Canyon Reference Lab | $141.00 | Needs review |
| CLM-2026-017054 | 2026-02-27 | Canyon Reference Lab | $141.00 | Approved |
| CLM-2026-033335 | 2026-03-24 | Canyon Heart Institute | $703.00 | Denied |
| CLM-2026-002754 | 2025-10-06 | Canyon Reference Lab | $167.00 | Denied |
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
Modifier 59 supported: distinct anatomical site documented.