CLM-2026-022130
Pinecrest Regional Medical Center, Emergency Medicine. Service 2026-07-26 at emergency room (POS 23). Received 2026-08-24.
Member
Resolved through the identity graph
- Member
- Joe Herrera
- Member ID
- UHC-92339-35
- Date of birth
- 1993-11-14
- Identity
- Verified4 records, confidence 0.93
- Claim record
- CLMCLM-432194
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7442
- Coverage period
- 2023-09-01 to present
- Deductible
- $604.75 of $1,500.0040%
- Out-of-pocket maximum
- $1,882.11 of $4,500.0042%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 1000861728
- Network
- Out of network
- Rendering NPI
- 1000861728
- Location
- Austin, TX · TIN 41-0807117
- 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 | $1,849.00 | $832.05 | $350.00 | $482.05 | Paid |
| Totals | $1,849.00 | $832.05 | $350.00 | $482.05 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- Patient account
- PA-993812
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-021265 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-07-26: - (PPO), effective 2023-09-01. | |
| Timely filing | Pass | Received 29 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Center2026-07-26 16:05
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-993812.pdf3 pages
Itemised statement totalling $1849.00 across 1 line.
- Er reported_report_PA-993812.pdf2 pages
Emergency department record: triage acuity 2, 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 engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007040 | 2026-06-14 | Unity Primary Care Associates | $277.00 | 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.