CLM-2026-019667
Pinecrest Regional Medical Center, Emergency Medicine. Service 2026-02-28 at emergency room (POS 23). Received 2026-03-28.
Member
Resolved through the identity graph
- Member
- Judith Rivera
- Member ID
- UHC-82345-54
- Date of birth
- 1953-09-08
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-406119
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6781
- Coverage period
- 2021-02-01 to present
- Deductible
- $206.06 of $2,500.008%
- Out-of-pocket maximum
- $4,441.17 of $10,000.0044%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 18 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 | $2,905.00 | $1,597.75 | $150.00 | $1,447.75 | Paid |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $744.00 | $409.20 | $0.00 | $409.20 | Paid |
| Totals | $3,649.00 | $2,006.95 | $150.00 | $1,856.95 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- Patient account
- PA-136165
- 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-006697 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-02-28: CHOICE-PLUS-PPO (PPO), effective 2021-02-01. | |
| Timely filing | Pass | Received 28 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 Center2026-02-28 15:42
Patient seen for pneumonia, unspecified organism.
Attachments
Documents received with the claim
- Itemized billitemized_PA-136165.pdf9 pages
Itemised statement totalling $3649.00 across 2 lines.
- Er reported_report_PA-136165.pdf5 pages
Emergency department record: triage acuity 4, chief complaint pneumonia, unspecified organism.
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-2026-010459 | 2026-05-04 | Meadow Family Practice | $36.00 | Approved |
| CLM-2026-030075 | 2026-01-01 | Meadow Clinical Laboratories | $38.00 | Approved |
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.