CLM-2026-022850
Pinecrest Regional Medical Center, Emergency Medicine. Service 2025-12-31 at emergency room (POS 23). Received 2026-02-03.
Member
Resolved through the identity graph
- Member
- Christine Ortiz
- Member ID
- UHC-56393-98
- Date of birth
- 1975-01-27
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-411854
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5674
- Coverage period
- 2021-01-01 to present
- Deductible
- $403.96 of $1,500.0027%
- Out-of-pocket maximum
- $1,339.37 of $6,000.0022%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 19 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 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,217.00 | $547.65 | $150.00 | $397.65 | Paid |
| 2 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1,2 | $2,497.00 | $1,123.65 | $0.00 | $1,123.65 | Paid |
| Totals | $3,714.00 | $1,671.30 | $150.00 | $1,521.30 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. J18.9 Pneumonia, unspecified organism
- Patient account
- PA-142616
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-010128 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-31: CHOICE-PLUS-PPO (PPO), effective 2021-01-01. | |
| Timely filing | Pass | Received 34 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 Center2025-12-31 14:05
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-142616.pdf7 pages
Itemised statement totalling $3714.00 across 2 lines.
- Er reported_report_PA-142616.pdf5 pages
Emergency department record: triage acuity 4, chief complaint chest pain, unspecified.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider 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-2026-008148 | 2026-02-23 | Summit Community Hospital | $1,660.00 | Needs review |
| CLM-2026-008147 | 2026-02-23 | Summit Community Hospital | $1,660.00 | 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.