CLM-2026-017779
Canyon Regional Medical Center, Emergency Medicine. Service 2026-03-09 at emergency room (POS 23). Received 2026-04-14.
Member
Resolved through the identity graph
- Member
- Aisha Gibson
- Member ID
- UHC-35385-80
- Date of birth
- 1941-12-19
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-416497
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-8576
- Coverage period
- 2025-03-01 to present
- Deductible
- $1,212.19 of $1,500.0081%
- Out-of-pocket maximum
- $59.11 of $3,000.002%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 1 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 / 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 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $2,949.00 | $1,621.95 | — | — | Review |
| 2 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,182.00 | $650.10 | — | — | Review |
| 3 | 96374 rev 0260 | IV push, single drug | 25 | 1 | 2 | $170.00 | $93.50 | — | — | Review |
| Totals | $4,301.00 | $2,365.55 | — | — | ||||||
- 1. S93.401A Sprain of unspecified ligament of right ankle, initial encounterprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-289692
- 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-022788 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-09: OPTIONS-PPO (PPO), effective 2025-03-01. | |
| Timely filing | Pass | Received 36 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 | Review | CO16 | Documentation incomplete: “Patient seen for sprain of unspecified ligament of right ankle, initial encounter. Note di”. 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: Canyon Regional Medical Center2026-03-09 13:05
Patient seen for sprain of unspecified ligament of right ankle, initial encounter. Note dictated; signature pending.
- SystemSystem: Claims system2026-04-14 04:18
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-04-14 09:15
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-289692.pdf6 pages
Itemised statement totalling $4301.00 across 3 lines.
- Er reported_report_PA-289692.pdf3 pages
Emergency department record: triage acuity 3, chief complaint sprain of unspecified ligament of right ankle, initial encounter.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Patient seen for sprain of unspecified ligament of right ankle, initial encounter. Note di”.
Other claims for this member
Same resolved identity
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
Development letter outstanding.