CLM-2026-020318
Riverside Community Hospital, Emergency Medicine. Service 2026-06-05 at emergency room (POS 23). Received 2026-07-05.
Member
Resolved through the identity graph
- Member
- Arthur Vega
- Member ID
- none on golden record
- Date of birth
- 1996-03-07
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-414023
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- MEDICARE-ADV-A MA group GRP-2934
- Coverage period
- 2023-11-01 to 2026-04-27
- Deductible
- $429.40 of $500.0086%
- Out-of-pocket maximum
- $164.30 of $1,000.0016%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 5 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 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $2,493.00 | $1,371.15 | — | — | DeniedCO27 |
| Totals | $2,493.00 | $1,371.15 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. J18.9 Pneumonia, unspecified organism
- Patient account
- PA-200071
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-002563; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Fail | CO27 | Date of service 2026-06-05 is after coverage terminated on 2026-04-27. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 30 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 Hospital2026-06-05 09:36
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-05 01:32
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-07-05 09:41
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-200071.pdf3 pages
Itemised statement totalling $2493.00 across 1 line.
- Er reported_report_PA-200071.pdf2 pages
Emergency department record: triage acuity 2, chief complaint chest pain, unspecified.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Member identity: Member record is in open steward case CASE-002563; payment withheld until the identity is confirmed. Eligibility: Date of service 2026-06-05 is after coverage terminated on 2026-04-27.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.