CLM-2026-018897
Pinecrest Regional Medical Center, Emergency Medicine. Service 2026-07-25 at emergency room (POS 23). Received 2026-08-10.
Member
Resolved through the identity graph
- Member
- Maria Cooper
- Member ID
- UHC-53767-89
- Date of birth
- 1963-02-22
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-407542
- Relationship
- Child, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-0386
- Coverage period
- 2022-08-01 to present
- Deductible
- $233.93 of $500.0047%
- Out-of-pocket maximum
- $391.67 of $1,000.0039%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 21 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 / REF711142
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 | $2,950.00 | $1,622.50 | $350.00 | $1,272.50 | Paid |
| 2 | 96374 rev 0260 | IV push, single drug | — | 1 | 2 | $150.00 | $82.50 | $0.00 | $82.50 | Paid |
| Totals | $3,100.00 | $1,705.00 | $350.00 | $1,355.00 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-588012
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-007490 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-25: CORE-HMO (HMO), effective 2022-08-01. | |
| Timely filing | Pass | Received 16 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 Center2026-07-25 12:43
Patient seen for unspecified abdominal pain.
Attachments
Documents received with the claim
- Itemized billitemized_PA-588012.pdf4 pages
Itemised statement totalling $3100.00 across 2 lines.
- Er reported_report_PA-588012.pdf5 pages
Emergency department record: triage acuity 3, 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 engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012066 | 2026-04-01 | Meadow Reference Lab | $187.00 | Denied |
| CLM-2026-005757 | 2026-01-15 | Lakeside Clinical Laboratories | $3,066.00 | 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.