CLM-2026-026043
Mesa Regional Medical Center, Emergency Medicine. Service 2026-08-25 at emergency room (POS 23). Received 2026-09-05.
Member
Resolved through the identity graph
- Member
- Mari Montgomery
- Member ID
- UHC-23118-53
- Date of birth
- 1949-04-12
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-421527
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-3394
- Coverage period
- 2021-01-01 to present
- Deductible
- $1,403.24 of $3,500.0040%
- Out-of-pocket maximum
- $1,839.94 of $14,000.0013%
- Copays
- office $30.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 3600007819
- Network
- Out of network
- Rendering NPI
- 3600007819
- Location
- Tampa, FL · TIN 90-5702951
- 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 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $186.00 | $83.70 | $83.70 | $0.00 | Paid |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | 25 | 1 | 2 | $600.00 | $270.00 | $0.00 | $270.00 | Paid |
| Totals | $786.00 | $353.70 | $83.70 | $270.00 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-242841
- 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-012795 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-25: MEDICARE-ADV-B (MA), effective 2021-01-01. | |
| Timely filing | Pass | Received 11 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: Mesa Regional Medical Center2026-08-25 12:37
Follow-up for pneumonia, unspecified organism. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-242841.pdf4 pages
Itemised statement totalling $786.00 across 2 lines.
- Er reported_report_PA-242841.pdf6 pages
Emergency department record: triage acuity 4, chief complaint pneumonia, unspecified organism.
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
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.