CLM-2026-024280
Pinecrest Regional Medical Center, Emergency Medicine. Service 2026-07-27 at emergency room (POS 23). Received 2026-09-08.
Member
Resolved through the identity graph
- Member
- Sophia Walker
- Member ID
- UHC-84938-93
- Date of birth
- 1996-05-18
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-425968
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-7826
- Coverage period
- 2024-02-01 to present
- Deductible
- $1,036.00 of $2,500.0041%
- Out-of-pocket maximum
- $3,016.40 of $10,000.0030%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 2061946325
- Network
- In network
- Rendering NPI
- 2061946325
- Location
- Denver, CO · TIN 60-4146079
- 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 | $984.00 | $541.20 | $350.00 | $191.20 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | 25 | 1 | 2 | $210.00 | $115.50 | $0.00 | $115.50 | Paid |
| 3 | 96374 rev 0260 | IV push, single drug | — | 1 | 1,2 | $197.00 | $108.35 | $0.00 | $108.35 | Paid |
| Totals | $1,391.00 | $765.05 | $350.00 | $415.05 | ||||||
- 1. R55 Syncope and collapseprincipal
- 2. J18.9 Pneumonia, unspecified organism
- Patient account
- PA-586205
- Frequency code
- 1 (original)
- Accident
- No
- 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-001014 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-27: MEDICARE-ADV-A (MA), effective 2024-02-01. | |
| Timely filing | Pass | Received 43 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 Pinecrest Regional Medical Center (2061946325). | |
| 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 Center2026-07-27 13:54
Established patient presents with syncope and collapse; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-586205.pdf2 pages
Itemised statement totalling $1391.00 across 3 lines.
- Er reported_report_PA-586205.pdf2 pages
Emergency department record: triage acuity 3, chief complaint syncope and collapse.
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-2026-034295 | 2026-09-28 | Mesa Physical Therapy | $272.00 | Approved |
| CLM-2026-005096 | 2026-06-26 | Valley Bone and Joint Center | $7,825.00 | Approved |
| CLM-2026-028467 | 2025-12-31 | Mesa Family Practice | $53.00 | 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.