CLM-2026-026020
Riverside Community Hospital, Emergency Medicine. Service 2026-05-11 at emergency room (POS 23). Received 2026-06-17.
Member
Resolved through the identity graph
- Member
- Frances Long
- Member ID
- none on golden record
- Date of birth
- 1959-08-23
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-422553
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by name and date of birth
- Plan
- NAVIGATE-HMO HMO group GRP-5916
- Coverage period
- 2024-02-01 to present
- Deductible
- $1,384.39 of $2,500.0055%
- Out-of-pocket maximum
- $2,295.97 of $10,000.0023%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 1928747868
- Network
- In network
- Rendering NPI
- 1928747868
- Location
- Mesa, AZ · TIN 30-6800456
- Authorisation / referral
- none / REF760204
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 | $1,602.00 | $881.10 | $250.00 | $631.10 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1,2 | $219.00 | $120.45 | $0.00 | $120.45 | Paid |
| Totals | $1,821.00 | $1,001.55 | $250.00 | $751.55 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. J18.9 Pneumonia, unspecified organism
- Patient account
- PA-781097
- 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-015660 (verified, link confidence 1.00). | |
| Eligibility | Note | Active on 2026-05-11: NAVIGATE-HMO (HMO), effective 2024-02-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 37 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 Riverside Community Hospital (1928747868). | |
| 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 Community Hospital2026-05-11 14:57
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-781097.pdf9 pages
Itemised statement totalling $1821.00 across 2 lines.
- Er reported_report_PA-781097.pdf2 pages
Emergency department record: triage acuity 2, chief complaint chest pain, unspecified.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Eligibility: Active on 2026-05-11: NAVIGATE-HMO (HMO), effective 2024-02-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010444 | 2026-01-17 | Mesa Diabetes Center | $531.00 | 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.