Claims workbench/CLM-2026-019014
Institutional claim · UB-04 · Paper

CLM-2026-019014

Desert Regional Medical Center, Emergency Medicine. Service 2026-10-07 at emergency room (POS 23). Received 2026-10-13.

Approved
Billed
$1,305.00
1 line
Allowed
$717.75
contract rate applied
Plan pays
$367.75
approved
Member owes
$350.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Brian Contreras
Member ID
UHC-26664-65
Date of birth
2005-02-15
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-406962
Relationship
Self

Coverage and accumulators

Found by member ID

Plan
NULL PPO group NULL
Coverage period
2023-09-01 to present
Deductible
$1,191.23 of $1,500.0079%
Out-of-pocket maximum
$2,693.91 of $6,000.0045%
Copays
office $25.00, specialist $60.00, emergency $350.00
Physical therapy visits
12 of 20 used

Provider

Billing and rendering

Billing provider
Desert Regional Medical Center
Emergency Medicine · taxonomy 207P00000X
NPI
8317237419
Network
In network
Rendering NPI
8317237419
Location
Austin, TX · TIN 55-6992539
Authorisation / referral
none / none

Service lines

UB-04: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199284
rev 0450
Emergency department visit, high severity—11$1,305.00$717.75$350.00$367.75Paid
Totals$1,305.00$717.75$350.00$367.75
Diagnoses (ICD-10-CM)
  • 1. R55 Syncope and collapseprincipal
Claim header
Patient account
PA-238120
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

CheckResultCodeDetail
Member identityPassAttached to MBR-046367 (provisional, link confidence 1.00).
EligibilityPassActive on 2026-10-07: NULL (PPO), effective 2023-09-01.
Timely filingPassReceived 6 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Desert Regional Medical Center (8317237419).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Desert Regional Medical Center2026-10-07 17:50

    Patient seen for syncope and collapse.

Attachments

Documents received with the claim

  • Itemized billitemized_PA-238120.pdf6 pages

    Itemised statement totalling $1305.00 across 1 line.

  • Er reported_report_PA-238120.pdf6 pages

    Emergency department record: triage acuity 3, chief complaint syncope and collapse.

Explanation of benefits

What the member will see

Amount billed
$1,305.00
Plan discount
$587.25
contracted rate
Plan paid
$367.75
You may owe
$350.00
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-22 12:44
    Clean claim.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

Clean claim: the rules engine approved it, so no AI review was needed.

Examiner decision

Approved by Claims rules engine; an examiner may still override

Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queueMember identity