CLM-2026-024408
Riverside Regional Medical Center, Emergency Medicine. Service 2026-01-01 at emergency room (POS 23). Received 2026-01-09.
Member
Resolved through the identity graph
- Member
- Nancy Price
- Member ID
- UHC-34209-49
- Date of birth
- 1998-01-02
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-423798
- Relationship
- Spouse, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-0109
- Coverage period
- 2024-06-01 to present
- Deductible
- $1,158.93 of $1,500.0077%
- Out-of-pocket maximum
- $1,057.20 of $4,500.0023%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 5185579187
- Network
- Out of network
- Rendering NPI
- 5185579187
- Location
- Tempe, AZ · TIN 24-5730797
- Authorisation / referral
- none / REF222824
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 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $218.00 | $119.90 | — | — | Review |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $988.00 | $543.40 | — | — | Review |
| Totals | $1,206.00 | $663.30 | — | — | ||||||
- 1. S93.401A Sprain of unspecified ligament of right ankle, initial encounterprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-651115
- Frequency code
- 1 (original)
- Accident
- Yes
- 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-002741 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-01: NAVIGATE-HMO (HMO), effective 2024-06-01. | |
| Timely filing | Pass | Received 8 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 | Review | NET | Out-of-network emergency visit. Payable at the in-network level if the prudent-layperson standard is met; review the ED record. Out-of-network provider |
| 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 Regional Medical Center2026-01-01 09:33
Patient seen for sprain of unspecified ligament of right ankle, initial encounter. Patient presented to the nearest emergency department with acute symptoms; care could not safely be delayed to reach an in-network facility.
- SystemSystem: Claims system2026-01-09 05:32
Out-of-network emergency visit. Emergency services are payable at the in-network level when the prudent-layperson standard is met.
Attachments
Documents received with the claim
- Itemized billitemized_PA-651115.pdf6 pages
Itemised statement totalling $1206.00 across 2 lines.
- Er reported_report_PA-651115.pdf5 pages
Emergency department record: triage acuity 2, chief complaint sprain of unspecified ligament of right ankle, initial encounter.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Provider network: Out-of-network emergency visit. Payable at the in-network level if the prudent-layperson standard is met; review the ED record.
- AI recommendationApproved2026-10-21 14:15The claim is for an out-of-network emergency visit that is payable at the in-network level if the prudent-layperson standard is met. The clinical note [N1] and emergency department record [A2] indicate that the patient presented with acute symptoms that could not safely be delayed, meeting the prudent-layperson standard. The claim is within the auto-adjudication ceiling and all other rules engine checks have passed. However, the billed amount is above $15,000.00, requiring human sign-off.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:15 · df191c4a
Other claims for this member
Same resolved identity
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
The claim is for an out-of-network emergency visit that is payable at the in-network level if the prudent-layperson standard is met. The clinical note [N1] and emergency department record [A2] indicate that the patient presented with acute symptoms that could not safely be delayed, meeting the prudent-layperson standard. The claim is within the auto-adjudication ceiling and all other rules engine checks have passed. However, the billed amount is above $15,000.00, requiring human sign-off.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Emergency: payable at in-network level.