CLM-2026-016227
Desert Regional Medical Center, Emergency Medicine. Service 2025-11-22 at emergency room (POS 23). Received 2026-01-04.
Member
Resolved through the identity graph
- Member
- Gerald Miller
- Member ID
- UHC-84890-95
- Date of birth
- 1983-04-03
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-403823
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-1300
- Coverage period
- 2024-04-01 to present
- Deductible
- $751.26 of $1,500.0050%
- Out-of-pocket maximum
- $824.21 of $3,000.0027%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 14 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 / REF663779
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 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $213.00 | $117.15 | — | — | Review |
| Totals | $213.00 | $117.15 | — | — | ||||||
- 1. R55 Syncope and collapseprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-837772
- Frequency code
- 1 (original)
- Accident
- No
- 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-001149 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-11-22: CORE-HMO (HMO), effective 2024-04-01. | |
| Timely filing | Pass | Received 43 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 | Review | CO16 | Documentation incomplete: “Established patient presents with syncope and collapse; symptoms reviewed and vitals withi”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Desert Regional Medical Center2025-11-22 16:22
Established patient presents with syncope and collapse; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-01-04 03:09
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-01-04 14:30
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-837772.pdf9 pages
Itemised statement totalling $213.00 across 1 line.
- Er reported_report_PA-837772.pdf3 pages
Emergency department record: triage acuity 2, chief complaint syncope and collapse.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Established patient presents with syncope and collapse; symptoms reviewed and vitals withi”.
- AI recommendationPended2026-10-21 14:05The claim is pended due to incomplete documentation. The clinical note is missing a signature, and a development letter has been sent to the provider [N1, N2]. The rules engine flagged the claim for incomplete documentation [R-completeness].
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:05 · e8484ba4
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033343 | 2026-07-03 | Unity Digestive Health Center | $2,479.00 | Approved |
| CLM-2026-029718 | 2026-04-27 | Summit Counseling Center | $557.00 | Approved |
| CLM-2026-024226 | 2025-12-08 | Cornerstone Reference Lab | $195.00 | Denied |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
- CO16 Claim lacks information needed for adjudication
The claim is pended due to incomplete documentation. The clinical note is missing a signature, and a development letter has been sent to the provider [N1, N2]. The rules engine flagged the claim for incomplete documentation [R-completeness].
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
- CO16 Claim lacks information needed for adjudication
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.