CLM-2026-018994
Riverside Community Hospital, Emergency Medicine. Service 2026-03-04 at emergency room (POS 23). Received 2026-03-10.
Member
Resolved through the identity graph
- Member
- Timothy Kelly
- Member ID
- UHC-36460-96
- Date of birth
- 1989-07-01
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-400874
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-0924
- Coverage period
- 2025-01-01 to present
- Deductible
- $1,108.07 of $1,500.0074%
- Out-of-pocket maximum
- $530.05 of $4,500.0012%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 1928747868
- Network
- In network
- Rendering NPI
- 1928747868
- Location
- Mesa, AZ · TIN 30-6800456
- 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 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $242.00 | $133.10 | $133.10 | $0.00 | Paid |
| 2 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,293.00 | $711.15 | $0.00 | $711.15 | Paid |
| 3 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $151.00 | $83.05 | $0.00 | $83.05 | Paid |
| Totals | $1,686.00 | $927.30 | $133.10 | $794.20 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-399318
- 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-018847 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-04: MEDICARE-ADV-B (MA), effective 2025-01-01. | |
| Timely filing | Pass | Received 6 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 Riverside Community Hospital (1928747868). | |
| 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 Community Hospital2026-03-04 14:09
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-399318.pdf7 pages
Itemised statement totalling $1686.00 across 3 lines.
- Er reported_report_PA-399318.pdf3 pages
Emergency department record: triage acuity 2, chief complaint chest pain, unspecified.
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
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.