CLM-2026-014501
Riverside Regional Medical Center, Emergency Medicine. Service 2026-05-15 at emergency room (POS 23). Received 2026-05-28.
Member
Resolved through the identity graph
- Member
- Victoria Salazar
- Member ID
- UHC-74312-49
- Date of birth
- 1970-06-13
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-420075
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group -
- Coverage period
- 2024-10-01 to present
- Deductible
- $724.24 of $2,500.0029%
- Out-of-pocket maximum
- $2,295.89 of $10,000.0023%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 5185579187
- Network
- Out of network
- Rendering NPI
- 5185579187
- Location
- Tempe, AZ · TIN 24-5730797
- Authorisation / referral
- none / REF975679
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 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $3,020.00 | $1,661.00 | — | — | Review |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 2 | $203.00 | $111.65 | — | — | Review |
| 3 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $830.00 | $456.50 | — | — | Review |
| Totals | $4,053.00 | $2,229.15 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-158983
- Frequency code
- 1 (original)
- Accident
- Yes
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-025057 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-05-15: NAVIGATE-HMO (HMO), effective 2024-10-01. | |
| Timely filing | Pass | Received 13 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 | Review | NET | Out-of-network emergency visit. Payable at the in-network level if the prudent-layperson standard is met; review the ED record. Out-of-network provider |
| 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: Riverside Regional Medical Center2026-05-15 12:43
Patient seen for chest pain, unspecified. Patient presented to the nearest emergency department with acute symptoms; care could not safely be delayed to reach an in-network facility.
- SystemSystem: Claims system2026-05-28 02:17
Out-of-network emergency visit. Emergency services are payable at the in-network level when the prudent-layperson standard is met.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-05-28 15:48
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-158983.pdf2 pages
Itemised statement totalling $4053.00 across 3 lines.
- Er reported_report_PA-158983.pdf4 pages
Emergency department record: triage acuity 4, chief complaint chest pain, unspecified.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Provider network: Out-of-network emergency visit. Payable at the in-network level if the prudent-layperson standard is met; review the ED record.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-013255 | 2026-09-29 | Lakeside Medical Group | $623.00 | Approved |
| CLM-2026-024360 | 2026-08-09 | Northgate Dermatology Clinic | $231.00 | 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
Emergency: payable at in-network level.