Claims workbench/CLM-2026-016198

Institutional claim · UB-04 · EDI 837I

CLM-2026-016198

Riverside Regional Medical Center, Emergency Medicine. Service 2026-01-29 at emergency room (POS 23). Received 2026-02-12.

ApprovedOut of network

Billed

$1,476.00

2 lines

Allowed

$664.20

contract rate applied

Plan pays

$514.20

approved

Member owes

$150.00

copay / deductible / 20% coinsurance

Rules engine

Clean

no reason codes

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Jeremy Reyes
Member ID: UHC-87372-54
Date of birth: 1973-02-03
Identity: Verified6 records, confidence 0.96
Claim record: CLMCLM-407926
Relationship: Self, Tempe, AZ

Coverage and accumulators

Found by member ID

Plan: MEDICARE-ADV-A MA group GRP-2281
Coverage period: 2025-03-01 to present
Deductible: $1,948.38 of $2,500.0078%
Out-of-pocket maximum: $1,869.80 of $7,500.0025%
Copays: office $40.00, specialist $40.00, emergency $150.00
Physical therapy visits: 10 of 20 used

Provider

Billing and rendering

Billing provider: Riverside Regional Medical Center
Emergency Medicine · taxonomy 207P00000X
NPI: 5185579187
Network: Out of network
Rendering NPI: 5185579187
Location: Tempe, AZ · TIN 24-5730797
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	99284 rev 0450	Emergency department visit, high severity	—	1	1	$1,250.00	$562.50	$150.00	$412.50	Paid
2	96374 rev 0260	IV push, single drug	—	1	2	$226.00	$101.70	$0.00	$101.70	Paid
Totals						$1,476.00	$664.20	$150.00	$514.20

Diagnoses (ICD-10-CM)

1. J18.9 Pneumonia, unspecified organismprincipal
2. S93.401A Sprain of unspecified ligament of right ankle, initial encounter

Claim header

Patient account: PA-540190
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	Detail
Member identity	Pass	Attached to MBR-003804 (verified, link confidence 0.96).
Eligibility	Pass	Active on 2026-01-29: MEDICARE-ADV-A (MA), effective 2025-03-01.
Timely filing	Pass	Received 14 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	Note	Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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.

Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Riverside Regional Medical Center2026-01-29 15:59
Follow-up for pneumonia, unspecified organism. Plan discussed, medications reconciled.

Attachments

Documents received with the claim

Itemized billitemized_PA-540190.pdf9 pages
Itemised statement totalling $1476.00 across 2 lines.
Er reported_report_PA-540190.pdf3 pages
Emergency department record: triage acuity 3, chief complaint pneumonia, unspecified organism.

Explanation of benefits

What the member will see

Amount billed

$1,476.00

Plan discount

$811.80

out-of-network allowance

Plan paid

$514.20

You may owe

$150.00

copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

Rules engineApproved2026-10-21 13:43
Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-020797	2026-05-21	Sunrise Medical Group	$287.00	Approved
CLM-2026-032883	2026-02-23	Desert Internal Medicine Associates	$242.00	Approved
CLM-2026-000822	2026-01-03	Heritage Imaging Center	$2,311.00	Needs review

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

Clean claim: the rules engine approved it, so no AI review was needed.

Examiner decision

Approved by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queue Member identity