CLM-2026-025008
Pinecrest Regional Medical Center, Emergency Medicine. Service 2025-11-21 at emergency room (POS 23). Received 2026-01-01.
Member
Resolved through the identity graph
- Member
- Ralph Vargas
- Member ID
- UHC-63428-97
- Date of birth
- 1969-06-27
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-401004
- Relationship
- Child, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group UNKNOWN
- Coverage period
- 2022-02-01 to present
- Deductible
- $1,645.65 of $2,500.0066%
- Out-of-pocket maximum
- $1,481.26 of $5,000.0030%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 1000861728
- Network
- Out of network
- Rendering NPI
- 1000861728
- Location
- Austin, TX · TIN 41-0807117
- Authorisation / referral
- none / REF649556
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 | 71046 rev 0320 | Chest X-ray, two views | 59 | 1 | 1 | $193.00 | $106.15 | — | — | Review |
| 2 | 99284 rev 0450 | Emergency department visit, high severity | 59 | 1 | 2 | $1,652.00 | $908.60 | — | — | Review |
| Totals | $1,845.00 | $1,014.75 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. J18.9 Pneumonia, unspecified organism
- Patient account
- PA-443615
- Frequency code
- 1 (original)
- Accident
- Yes
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000260 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-11-21: NAVIGATE-HMO (HMO), effective 2022-02-01. | |
| Timely filing | Pass | Received 41 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) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Center2025-11-21 10:06
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range. Patient presented to the nearest emergency department with acute symptoms; care could not safely be delayed to reach an in-network facility.
- SystemSystem: Claims system2026-01-01 05:53
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-443615.pdf7 pages
Itemised statement totalling $1845.00 across 2 lines.
- Er reported_report_PA-443615.pdf2 pages
Emergency department record: triage acuity 4, chief complaint chest pain, unspecified.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Provider network: Out-of-network emergency visit. Payable at the in-network level if the prudent-layperson standard is met; review the ED record. Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
- AI recommendationApproved2026-10-22 12:49The claim is for an out-of-network emergency visit, which is payable at the in-network level if the prudent-layperson standard is met. The clinical note [N1] indicates that the patient presented with acute symptoms and care could not safely be delayed to reach an in-network facility, meeting the prudent-layperson standard. The claim is within the auto-adjudication ceiling and all required documentation is present. The use of modifier 59 on a normally bundled code pair is acceptable as the clinical note documents a distinct procedural service. The claim is approved with a human sign-off required due to the billed amount being above $15,000.00.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:05 · 6700698e
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-22 12:49 · 5fac2f20
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, which is payable at the in-network level if the prudent-layperson standard is met. The clinical note [N1] indicates that the patient presented with acute symptoms and care could not safely be delayed to reach an in-network facility, meeting the prudent-layperson standard. The claim is within the auto-adjudication ceiling and all required documentation is present. The use of modifier 59 on a normally bundled code pair is acceptable as the clinical note documents a distinct procedural service. The claim is approved with a human sign-off required due to the billed amount being above $15,000.00.
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.