CLM-2026-014050
Desert Regional Medical Center, Emergency Medicine. Service 2026-02-10 at emergency room (POS 23). Received 2026-02-16.
Member
Resolved through the identity graph
- Member
- Katherine Cox
- Member ID
- UHC-99478-30
- Date of birth
- 2008-07-13
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-424283
- Relationship
- Child, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-0842
- Coverage period
- 2024-10-01 to present
- Deductible
- $161.36 of $1,000.0016%
- Out-of-pocket maximum
- $951.03 of $2,000.0048%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 12 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 / 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 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $1,006.00 | $553.30 | $250.00 | $303.30 | Paid |
| 2 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | 25 | 1 | 2 | $2,960.00 | $1,628.00 | $0.00 | $1,628.00 | Paid |
| 3 | 99284 rev 0450 | Emergency department visit, high severity | 25 | 1 | 1 | $1,348.00 | $741.40 | $0.00 | $741.40 | Paid |
| Totals | $5,314.00 | $2,922.70 | $250.00 | $2,672.70 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- Patient account
- PA-719307
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-004190 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-10: OPTIONS-PPO (PPO), effective 2024-10-01. | |
| Timely filing | Pass | Received 6 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 Center2026-02-10 13:11
Established patient presents with pneumonia, unspecified organism; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-719307.pdf7 pages
Itemised statement totalling $5314.00 across 3 lines.
- Er reported_report_PA-719307.pdf6 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 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-027066 | 2026-07-06 | Heritage Digestive Health Center | $1,331.00 | Approved |
| CLM-2026-015544 | 2026-02-20 | Meadow Family Practice | $304.00 | 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.