CLM-2026-016640
Canyon Regional Medical Center, Emergency Medicine. Service 2026-08-28 at emergency room (POS 23). Received 2026-09-17.
Member
Resolved through the identity graph
- Member
- Roger Powell
- Member ID
- UHC-24883-81
- Date of birth
- 1993-07-07
- Identity
- Verified5 records, confidence 0.94
- Claim record
- CLMCLM-423076
- Relationship
- Spouse, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-0284
- Coverage period
- 2023-05-01 to 2026-08-23
- Deductible
- $797.22 of $1,000.0080%
- Out-of-pocket maximum
- $964.21 of $2,000.0048%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 7874072318
- Network
- In network
- Rendering NPI
- 7874072318
- Location
- Tampa, FL · TIN 53-7384078
- Authorisation / referral
- none / REF420279
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 | $913.00 | $502.15 | — | — | DeniedCO27 |
| 2 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $170.00 | $93.50 | — | — | DeniedCO27 |
| Totals | $1,083.00 | $595.65 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-801064
- 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-020831 (verified, link confidence 0.94). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-28 is after coverage terminated on 2026-08-23. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 20 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 Canyon Regional Medical Center (7874072318). | |
| 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: Canyon Regional Medical Center2026-08-28 11:19
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-17 06:48
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-09-17 13:30
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-801064.pdf7 pages
Itemised statement totalling $1083.00 across 2 lines.
- Er reported_report_PA-801064.pdf4 pages
Emergency department record: triage acuity 2, chief complaint unspecified abdominal pain.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-08-28 is after coverage terminated on 2026-08-23.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-008100 | 2026-04-10 | Valley Community Hospital | $359.00 | Needs review |
| CLM-2026-022895 | 2026-04-05 | Canyon Primary Care Associates | $339.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.