CLM-2026-018059
Riverside Regional Medical Center, Emergency Medicine. Service 2026-09-16 at emergency room (POS 23). Received 2026-10-18.
Member
Resolved through the identity graph
- Member
- Donald Gonzales
- Member ID
- UHC-12549-84
- Date of birth
- 2006-10-09
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-414855
- Relationship
- Spouse, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3461
- Coverage period
- 2024-09-01 to present
- Deductible
- $281.02 of $1,500.0019%
- Out-of-pocket maximum
- $195.61 of $6,000.003%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Regional Medical CenterEmergency 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 | $1,519.00 | $683.55 | $250.00 | $433.55 | Paid |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 2 | $791.00 | $355.95 | $0.00 | $355.95 | Paid |
| Totals | $2,310.00 | $1,039.50 | $250.00 | $789.50 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- Patient account
- PA-367933
- 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-000951 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-16: OPTIONS-PPO (PPO), effective 2024-09-01. | |
| Timely filing | Pass | Received 32 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Riverside Regional Medical Center2026-09-16 09:31
Patient seen for pneumonia, unspecified organism.
Attachments
Documents received with the claim
- Itemized billitemized_PA-367933.pdf2 pages
Itemised statement totalling $2310.00 across 2 lines.
- Er reported_report_PA-367933.pdf2 pages
Emergency department record: triage acuity 3, chief complaint pneumonia, unspecified organism.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider 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-2026-022757 | 2026-09-06 | Sunrise Internal Medicine Associates | $108.00 | Approved |
| CLM-2026-005264 | 2026-03-09 | Northgate Medical Group | $45.00 | 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.