CLM-2026-020293
Pinecrest Regional Medical Center, Emergency Medicine. Service 2026-03-03 at emergency room (POS 23). Received 2026-04-11.
Member
Resolved through the identity graph
- Member
- Marilyn Soto
- Member ID
- UHC-68446-58
- Date of birth
- 1943-08-15
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-421289
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8375
- Coverage period
- 2021-11-01 to present
- Deductible
- $841.37 of $3,500.0024%
- Out-of-pocket maximum
- $3,292.72 of $14,000.0024%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 1 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 / REF192808
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 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,675.00 | $921.25 | $250.00 | $671.25 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | 25 | 1 | 1 | $175.00 | $96.25 | $0.00 | $96.25 | Paid |
| 3 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $984.00 | $541.20 | $0.00 | $541.20 | Paid |
| Totals | $2,834.00 | $1,558.70 | $250.00 | $1,308.70 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-862702
- 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-025148 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-03-03: CORE-HMO (HMO), effective 2021-11-01. | |
| Timely filing | Pass | Received 39 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 Center2026-03-03 09:10
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-862702.pdf9 pages
Itemised statement totalling $2834.00 across 3 lines.
- Er reported_report_PA-862702.pdf4 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
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.