CLM-2026-026084
Riverside Community Hospital, Emergency Medicine. Service 2026-02-02 at emergency room (POS 23). Received 2026-03-06.
Member
Resolved through the identity graph
- Member
- Hannah Burke
- Member ID
- UHC-00120-23
- Date of birth
- 2008-11-14
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-400830
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-2277
- Coverage period
- 2022-01-01 to present
- Deductible
- $2,918.86 of $3,500.0083%
- Out-of-pocket maximum
- $2,995.07 of $14,000.0021%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 15 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 / REF887652
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 | $873.00 | $480.15 | $150.00 | $330.15 | Paid |
| 2 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 2 | $1,032.00 | $567.60 | $0.00 | $567.60 | Paid |
| Totals | $1,905.00 | $1,047.75 | $150.00 | $897.75 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-508176
- Frequency code
- 1 (original)
- Accident
- Yes
- 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-015128 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-02: CORE-HMO (HMO), effective 2022-01-01. | |
| Timely filing | Pass | Received 32 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 Hospital2026-02-02 12:52
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-508176.pdf8 pages
Itemised statement totalling $1905.00 across 2 lines.
- Er reported_report_PA-508176.pdf2 pages
Emergency department record: triage acuity 4, chief complaint unspecified abdominal pain.
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-2026-014087 | 2026-03-03 | Canyon Primary Care Associates | $498.00 | Approved |
| CLM-2026-006119 | 2026-02-04 | Desert Reference Lab | $132.00 | 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.