CLM-2026-025073
Cornerstone Regional Medical Center, Emergency Medicine. Service 2026-03-01 at emergency room (POS 23). Received 2026-04-13.
Member
Resolved through the identity graph
- Member
- Samuel Mendoza
- Member ID
- UHC-48138-76
- Date of birth
- 1979-01-02
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-422132
- Relationship
- Spouse, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-3575
- Coverage period
- 2025-03-01 to present
- Deductible
- $278.58 of $500.0056%
- Out-of-pocket maximum
- $813.15 of $2,000.0041%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 1149569109
- Network
- In network
- Rendering NPI
- 1149569109
- Location
- Nashville, TN · TIN 45-8232836
- 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 | $1,972.00 | $1,084.60 | $350.00 | $734.60 | Paid |
| 2 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 2 | $1,508.00 | $829.40 | $0.00 | $829.40 | Paid |
| Totals | $3,480.00 | $1,914.00 | $350.00 | $1,564.00 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. R55 Syncope and collapse
- Patient account
- PA-937385
- Frequency code
- 1 (original)
- Accident
- Yes
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-025682 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-01: NULL (PPO), effective 2025-03-01. | |
| 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 Cornerstone Regional Medical Center (1149569109). | |
| 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: Cornerstone Regional Medical Center2026-03-01 11:54
Patient seen for pneumonia, unspecified organism.
Attachments
Documents received with the claim
- Itemized billitemized_PA-937385.pdf5 pages
Itemised statement totalling $3480.00 across 2 lines.
- Er reported_report_PA-937385.pdf6 pages
Emergency department record: triage acuity 3, chief complaint pneumonia, unspecified organism.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021745 | 2026-05-11 | Northgate Clinical Laboratories | $216.00 | Approved |
| CLM-2026-019182 | 2026-05-01 | Meadow Physical Therapy | $6,114.00 | Needs review |
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.