CLM-2026-018543
Pinecrest Regional Medical Center, Emergency Medicine. Service 2026-06-02 at emergency room (POS 23). Received 2026-07-16.
Member
Resolved through the identity graph
- Member
- Elijah Bishop
- Member ID
- UHC-69416-72
- Date of birth
- 1965-08-08
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-404780
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group UNKNOWN
- Coverage period
- 2023-04-01 to present
- Deductible
- $2,866.11 of $3,500.0082%
- Out-of-pocket maximum
- $321.57 of $10,500.003%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 2061946325
- Network
- In network
- Rendering NPI
- 1269847210 (Summit Regional Medical Center)
- Location
- Denver, CO · TIN 60-4146079
- 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 | $1,019.00 | $560.45 | — | — | Review |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $723.00 | $397.65 | — | — | Review |
| Totals | $1,742.00 | $958.10 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-151951
- Frequency code
- 1 (original)
- Accident
- Yes
- 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-037465 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-06-02: SELECT-EPO (EPO), effective 2023-04-01. | |
| Timely filing | Pass | Received 44 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-018542, billed by a different provider. Possible duplicate |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Pinecrest Regional Medical Center (2061946325). | |
| 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: Pinecrest Regional Medical Center2026-06-02 15:09
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-07-16 00:08
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-07-16 11:32
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-151951.pdf7 pages
Itemised statement totalling $1742.00 across 2 lines.
- Er reported_report_PA-151951.pdf4 pages
Emergency department record: triage acuity 2, chief complaint chest pain, unspecified.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Duplicate check: Same member, date of service and procedures as CLM-2026-018542, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012714 | 2026-08-07 | Heritage Digestive Health Center | $271.00 | Approved |
| CLM-2026-006469 | 2026-07-28 | Unity Family Practice | $499.00 | Approved |
| CLM-2026-018542 | 2026-06-02 | Summit Regional Medical Center | $1,742.00 | Approved |
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
Different billing provider; separately payable.