CLM-2026-023773
Riverside Community Hospital, Emergency Medicine. Service 2026-04-26 at emergency room (POS 23). Received 2026-05-06.
Member
Resolved through the identity graph
- Member
- Joyce Perry
- Member ID
- UHC-51288-35
- Date of birth
- 1972-09-08
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-406659
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8864
- Coverage period
- 2023-07-01 to 2026-03-19
- Deductible
- $293.63 of $3,500.008%
- Out-of-pocket maximum
- $2,469.65 of $10,500.0024%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 10 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 | $2,852.00 | $1,568.60 | — | — | DeniedCO27 |
| Totals | $2,852.00 | $1,568.60 | — | — | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- Patient account
- PA-561855
- 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-029317 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-26 is after coverage terminated on 2026-03-19. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 10 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 Hospital2026-04-26 13:21
Follow-up for pneumonia, unspecified organism. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-05-06 04:07
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-05-06 09:42
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-561855.pdf4 pages
Itemised statement totalling $2852.00 across 1 line.
- Er reported_report_PA-561855.pdf3 pages
Emergency department record: triage acuity 3, chief complaint pneumonia, unspecified organism.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-04-26 is after coverage terminated on 2026-03-19.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021494 | 2026-05-29 | Lakeside Bone and Joint Center | $51,761.00 | Denied |
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.