CLM-2026-016039
Pinecrest Regional Medical Center, Emergency Medicine. Service 2025-12-20 at emergency room (POS 23). Received 2026-01-10.
Member
Resolved through the identity graph
- Member
- Ana Stewart
- Member ID
- UHC-41485-25
- Date of birth
- 1943-05-23
- Identity
- Verified2 records, confidence 0.98
- Claim record
- CLMCLM-408639
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-1013
- Coverage period
- 2021-06-01 to present
- Deductible
- $489.09 of $1,500.0033%
- Out-of-pocket maximum
- $1,123.86 of $3,000.0037%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 1000861728
- Network
- Out of network
- Rendering NPI
- 1000861728
- Location
- Austin, TX · TIN 41-0807117
- 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 | $168.00 | $92.40 | — | — | Review |
| 2 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | 25 | 1 | 1 | $2,795.00 | $1,537.25 | — | — | Review |
| Totals | $2,963.00 | $1,629.65 | — | — | ||||||
- 1. S93.401A Sprain of unspecified ligament of right ankle, initial encounterprincipal
- Patient account
- PA-773111
- Frequency code
- 1 (original)
- Accident
- No
- 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-003018 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2025-12-20: SELECT-EPO (EPO), effective 2021-06-01. | |
| Timely filing | Pass | Received 21 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: Pinecrest Regional Medical Center2025-12-20 13:45
Established patient presents with sprain of unspecified ligament of right ankle, initial encounter; symptoms reviewed and vitals within expected range. Patient presented to the nearest emergency department with acute symptoms; care could not safely be delayed to reach an in-network facility.
- SystemSystem: Claims system2026-01-10 01:14
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)2026-01-10 10:32
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-773111.pdf8 pages
Itemised statement totalling $2963.00 across 2 lines.
- Er reported_report_PA-773111.pdf2 pages
Emergency department record: triage acuity 2, chief complaint sprain of unspecified ligament of right ankle, initial encounter.
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.
- AI recommendationApproved2026-10-23 17:07The claim is for an out-of-network emergency visit, which is payable at the in-network level if the prudent-layperson standard is met. The clinical note [N1] indicates that the patient presented with acute symptoms and care could not safely be delayed to reach an in-network facility, meeting the prudent-layperson standard. The claim is within the auto-adjudication ceiling and all required documentation is present. The claim is approved with a human sign-off required due to the billed amount being above $15,000.00.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-22 12:42 · a261977d
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-23 17:07 · 2cdbaa51
Other claims for this member
Same resolved identity
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
The claim is for an out-of-network emergency visit, which is payable at the in-network level if the prudent-layperson standard is met. The clinical note [N1] indicates that the patient presented with acute symptoms and care could not safely be delayed to reach an in-network facility, meeting the prudent-layperson standard. The claim is within the auto-adjudication ceiling and all required documentation is present. The claim is approved with a human sign-off required due to the billed amount being above $15,000.00.
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.