CLM-2026-024883
Pinecrest Regional Medical Center, Emergency Medicine. Service 2026-05-08 at emergency room (POS 23). Received 2026-06-06.
Member
Resolved through the identity graph
- Member
- Steven Griffin
- Member ID
- UHC-31694-08
- Date of birth
- 1964-06-03
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-402306
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-5962
- Coverage period
- 2022-12-01 to 2026-01-25
- Deductible
- $1,994.18 of $3,500.0057%
- Out-of-pocket maximum
- $1,224.76 of $10,500.0012%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 17 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 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,789.00 | $983.95 | — | — | DeniedCO27 |
| 2 | 96374 rev 0260 | IV push, single drug | — | 1 | 1,2 | $233.00 | $128.15 | — | — | DeniedCO27 |
| Totals | $2,022.00 | $1,112.10 | — | — | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-970721
- Frequency code
- 1 (original)
- Accident
- Yes
- 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-031107 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-08 is after coverage terminated on 2026-01-25. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 29 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 Center2026-05-08 15:10
Patient seen for pneumonia, unspecified organism.
- SystemSystem: Claims system2026-06-06 02:14
Attachments
Documents received with the claim
- Itemized billitemized_PA-970721.pdf4 pages
Itemised statement totalling $2022.00 across 2 lines.
- Er reported_report_PA-970721.pdf4 pages
Emergency department record: triage acuity 2, 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 2026-05-08 is after coverage terminated on 2026-01-25.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005301 | 2026-08-29 | Heritage Rehabilitation Center | $234.00 | Denied |
| CLM-2026-030905 | 2026-04-26 | Sunrise Physical Therapy | $246.00 | 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.