CLM-2026-025818
Pinecrest Regional Medical Center, Emergency Medicine. Service 2026-02-18 at emergency room (POS 23). Received 2026-02-20.
Member
Resolved through the identity graph
- Member
- Peter Ford
- Member ID
- UHC-45344-03
- Date of birth
- 1991-10-23
- Identity
- Verified6 records, confidence 0.97
- Claim record
- CLMCLM-421610
- Relationship
- Child, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1614
- Coverage period
- 2022-10-01 to present
- Deductible
- $253.91 of $500.0051%
- Out-of-pocket maximum
- $331.81 of $1,000.0033%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 2061946325
- Network
- In network
- Rendering NPI
- 2061946325
- Location
- Denver, CO · TIN 60-4146079
- 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 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $816.00 | $448.80 | $350.00 | $98.80 | Paid |
| Totals | $816.00 | $448.80 | $350.00 | $98.80 | ||||||
- 1. R55 Syncope and collapseprincipal
- Patient account
- PA-913996
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-009536 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-02-18: CHOICE-PLUS-PPO (PPO), effective 2022-10-01. | |
| Timely filing | Pass | Received 2 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 Pinecrest Regional Medical Center (2061946325). | |
| 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: Pinecrest Regional Medical Center2026-02-18 13:51
Patient seen for syncope and collapse.
Attachments
Documents received with the claim
- Itemized billitemized_PA-913996.pdf5 pages
Itemised statement totalling $816.00 across 1 line.
- Er reported_report_PA-913996.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 engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011979 | 2026-06-08 | Unity Primary Care Associates | $269.00 | Denied |
| CLM-2026-011978 | 2026-06-08 | Unity Primary Care Associates | $269.00 | 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.