CLM-2026-023519
Riverside Community Hospital, Emergency Medicine. Service 2026-03-26 at emergency room (POS 23). Received 2026-04-23.
Member
Resolved through the identity graph
- Member
- Megan Brown
- Member ID
- UHC-23638-95
- Date of birth
- 1999-05-07
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-411291
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-4781
- Coverage period
- 2024-01-01 to present
- Deductible
- $2,258.31 of $3,500.0065%
- Out-of-pocket maximum
- $5,589.83 of $14,000.0040%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 17 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 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $947.00 | $520.85 | $350.00 | $170.85 | Paid |
| 2 | 96374 rev 0260 | IV push, single drug | — | 1 | 2 | $193.00 | $106.15 | $0.00 | $106.15 | Paid |
| 3 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $1,920.00 | $1,056.00 | $0.00 | $1,056.00 | Paid |
| Totals | $3,060.00 | $1,683.00 | $350.00 | $1,333.00 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-317558
- Frequency code
- 1 (original)
- Accident
- Yes
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-017912 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-26: MEDICARE-ADV-B (MA), effective 2024-01-01. | |
| Timely filing | Pass | Received 28 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 Hospital2026-03-26 16:06
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-317558.pdf5 pages
Itemised statement totalling $3060.00 across 3 lines.
- Er reported_report_PA-317558.pdf2 pages
Emergency department record: triage acuity 2, 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 engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031220 | 2026-02-28 | Mesa Orthopedic Specialists | $8,449.00 | Approved |
| CLM-2026-029971 | 2026-02-28 | Meadow GI Associates | $222.00 | 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.