Claims workbench/CLM-2026-020003
Institutional claim · UB-04 · EDI 837I

CLM-2026-020003

Pinecrest Regional Medical Center, Emergency Medicine. Service 2026-08-18 at emergency room (POS 23). Received 2026-09-22.

Approved
Billed
$140.00
1 line
Allowed
$77.00
contract rate applied
Plan pays
$0.00
approved
Member owes
$77.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Lisa Rivera
Member ID
UHC-02876-16
Date of birth
1938-10-09
Identity
Verified3 records, confidence 0.99
Claim record
CLMCLM-413687
Relationship
Self, Mesa, AZ

Coverage and accumulators

Found by member ID

Plan
CHOICE-PLUS-PPO PPO group GRP-6558
Coverage period
2025-03-01 to present
Deductible
$211.30 of $500.0042%
Out-of-pocket maximum
$225.95 of $1,000.0023%
Copays
office $20.00, specialist $40.00, emergency $250.00
Physical therapy visits
22 of 20 used

Provider

Billing and rendering

Billing provider
Pinecrest Regional Medical Center
Emergency 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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
196374
rev 0260
IV push, single drug—11$140.00$77.00$77.00$0.00Paid
Totals$140.00$77.00$77.00$0.00
Diagnoses (ICD-10-CM)
  • 1. R10.9 Unspecified abdominal painprincipal
  • 2. R55 Syncope and collapse
Claim header
Patient account
PA-951188
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

CheckResultCodeDetail
Member identityPassAttached to MBR-022759 (verified, link confidence 0.99).
EligibilityPassActive on 2026-08-18: - (PPO), effective 2025-03-01.
Timely filingPassReceived 35 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Pinecrest Regional Medical Center (2061946325).
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 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Pinecrest Regional Medical Center2026-08-18 15:05

    Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.

Attachments

Documents received with the claim

  • Itemized billitemized_PA-951188.pdf7 pages

    Itemised statement totalling $140.00 across 1 line.

  • Er reported_report_PA-951188.pdf2 pages

    Emergency department record: triage acuity 3, chief complaint unspecified abdominal pain.

Explanation of benefits

What the member will see

Amount billed
$140.00
Plan discount
$63.00
contracted rate
Plan paid
$0.00
You may owe
$77.00
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-21 13:43
    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