CLM-2026-017919
Cornerstone Regional Medical Center, Emergency Medicine. Service 2026-07-18 at emergency room (POS 23). Received 2026-08-31.
Member
Resolved through the identity graph
- Member
- Harold Reynolds
- Member ID
- UHC-89498-76
- Date of birth
- 1985-09-02
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-405802
- Relationship
- Child, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-9128
- Coverage period
- 2024-12-01 to present
- Deductible
- $365.62 of $3,500.0010%
- Out-of-pocket maximum
- $3,154.77 of $14,000.0023%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 1149569109
- Network
- In network
- Rendering NPI
- 1149569109
- Location
- Nashville, TN · TIN 45-8232836
- 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 | $1,640.00 | $902.00 | $250.00 | $652.00 | Paid |
| 2 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $2,936.00 | $1,614.80 | $0.00 | $1,614.80 | Paid |
| Totals | $4,576.00 | $2,516.80 | $250.00 | $2,266.80 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-429786
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-005426 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-18: MEDICARE-ADV-A (MA), effective 2024-12-01. | |
| Timely filing | Pass | Received 44 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 Cornerstone Regional Medical Center (1149569109). | |
| 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: Cornerstone Regional Medical Center2026-07-18 14:20
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-429786.pdf6 pages
Itemised statement totalling $4576.00 across 2 lines.
- Er reported_report_PA-429786.pdf3 pages
Emergency department record: triage acuity 2, chief complaint unspecified abdominal pain.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012031 | 2025-12-20 | Evergreen GI Associates | $1,708.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.