CLM-2026-025223
Desert Regional Medical Center, Emergency Medicine. Service 2026-04-27 at emergency room (POS 23). Received 2026-06-07.
Member
Resolved through the identity graph
- Member
- Henry Jacobs
- Member ID
- UHC-84856-83
- Date of birth
- 1962-05-18
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-431473
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-2349
- Coverage period
- 2024-10-01 to present
- Deductible
- $719.77 of $3,500.0021%
- Out-of-pocket maximum
- $888.47 of $7,000.0013%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 8317237419
- Network
- In network
- Rendering NPI
- 8317237419
- Location
- Austin, TX · TIN 55-6992539
- Authorisation / referral
- none / REF955584
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 | $2,630.00 | $1,446.50 | $250.00 | $1,196.50 | Paid |
| 2 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,799.00 | $989.45 | $0.00 | $989.45 | Paid |
| Totals | $4,429.00 | $2,435.95 | $250.00 | $2,185.95 | ||||||
- 1. R55 Syncope and collapseprincipal
- 2. J18.9 Pneumonia, unspecified organism
- 3. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- Patient account
- PA-493999
- 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-000022 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-27: CORE-HMO (HMO), effective 2024-10-01. | |
| 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 | Pass | In-network provider Desert Regional Medical Center (8317237419). | |
| 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: Desert Regional Medical Center2026-04-27 18:40
Patient seen for syncope and collapse.
Attachments
Documents received with the claim
- Itemized billitemized_PA-493999.pdf3 pages
Itemised statement totalling $4429.00 across 2 lines.
- Er reported_report_PA-493999.pdf4 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 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-026431 | 2025-11-29 | Northgate Internal Medicine Associates | $350.00 | Needs review |
| CLM-2026-026430 | 2025-11-29 | Northgate Internal Medicine Associates | $350.00 | 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.