CLM-2026-018634
Pinecrest Regional Medical Center, Emergency Medicine. Service 2026-03-20 at emergency room (POS 23). Received 2026-04-26.
Member
Resolved through the identity graph
- Member
- Carlos Gibson
- Member ID
- UHC-74409-30
- Date of birth
- 1939-07-05
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-417757
- Relationship
- Spouse, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-5464
- Coverage period
- 2025-05-01 to 2026-08-15
- Deductible
- $223.33 of $1,000.0022%
- Out-of-pocket maximum
- $1,475.31 of $4,000.0037%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 2061946325
- Network
- In network
- Rendering NPI
- 2061946325
- 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 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $1,908.00 | $1,049.40 | $350.00 | $699.40 | Paid |
| 2 | 96374 rev 0260 | IV push, single drug | — | 1 | 2 | $219.00 | $120.45 | $0.00 | $120.45 | Paid |
| Totals | $2,127.00 | $1,169.85 | $350.00 | $819.85 | ||||||
- 1. R55 Syncope and collapseprincipal
- 2. R07.9 Chest pain, unspecified
- 3. R10.9 Unspecified abdominal pain
- Patient account
- PA-745815
- 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-010806 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-20: MEDICARE-ADV-B (MA), effective 2025-05-01, terms 2026-08-15. | |
| Timely filing | Pass | Received 37 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 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 Center2026-03-20 09:51
Patient seen for syncope and collapse.
Attachments
Documents received with the claim
- Itemized billitemized_PA-745815.pdf4 pages
Itemised statement totalling $2127.00 across 2 lines.
- Er reported_report_PA-745815.pdf5 pages
Emergency department record: triage acuity 2, chief complaint syncope and collapse.
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-2026-026422 | 2026-06-06 | Canyon Reference Lab | $81.00 | Needs review |
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.