CLM-2026-025278
Desert Regional Medical Center, Emergency Medicine. Service 2026-01-04 at emergency room (POS 23). Received 2026-01-30.
Member
Resolved through the identity graph
- Member
- Mary Martin
- Member ID
- UHC-02890-69
- Date of birth
- 1983-10-15
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-411507
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group GRP-5491
- Coverage period
- 2024-04-01 to present
- Deductible
- $3,039.91 of $3,500.0087%
- Out-of-pocket maximum
- $2,614.68 of $7,000.0037%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 16 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 / 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 | $1,051.00 | $578.05 | $250.00 | $328.05 | Paid |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $678.00 | $372.90 | $0.00 | $372.90 | Paid |
| 3 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $198.00 | $108.90 | $0.00 | $108.90 | Paid |
| Totals | $1,927.00 | $1,059.85 | $250.00 | $809.85 | ||||||
- 1. R55 Syncope and collapseprincipal
- Patient account
- PA-601161
- Frequency code
- 1 (original)
- Accident
- No
- 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-008963 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-04: UNKNOWN (PPO), effective 2024-04-01. | |
| Timely filing | Pass | Received 26 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 Center2026-01-04 16:17
Follow-up for syncope and collapse. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-601161.pdf8 pages
Itemised statement totalling $1927.00 across 3 lines.
- Er reported_report_PA-601161.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 12:44Clean claim.
Other claims for this member
Same resolved identity
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.