CLM-2026-025211
Riverside Regional Medical Center, Emergency Medicine. Service 2026-08-10 at emergency room (POS 23). Received 2026-08-27.
Member
Resolved through the identity graph
- Member
- Kimberly Miller
- Member ID
- UHC-03074-28
- Date of birth
- 2002-12-17
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-401504
- Relationship
- Child, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-7300
- Coverage period
- 2021-11-01 to present
- Deductible
- $864.67 of $1,500.0058%
- Out-of-pocket maximum
- $995.05 of $6,000.0017%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 13 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 / 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 | $2,750.00 | $1,237.50 | $350.00 | $887.50 | Paid |
| Totals | $2,750.00 | $1,237.50 | $350.00 | $887.50 | ||||||
- 1. R55 Syncope and collapseprincipal
- Patient account
- PA-445271
- Frequency code
- 1 (original)
- Accident
- No
- 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-016176 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-10: OPTIONS-PPO (PPO), effective 2021-11-01. | |
| Timely filing | Pass | Received 17 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Center2026-08-10 14:39
Patient seen for syncope and collapse.
Attachments
Documents received with the claim
- Itemized billitemized_PA-445271.pdf3 pages
Itemised statement totalling $2750.00 across 1 line.
- Er reported_report_PA-445271.pdf3 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 engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009426 | 2026-04-11 | Sunrise Cardiovascular Associates | $346.00 | Approved |
| CLM-2026-025120 | 2026-03-13 | Lakeside Internal Medicine Associates | $466.00 | 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.