CLM-2026-026514
Canyon Regional Medical Center, Emergency Medicine. Service 2026-01-24 at emergency room (POS 23). Received 2026-03-05.
Member
Resolved through the identity graph
- Member
- Brittany Marquez
- Member ID
- UHC-71596-90
- Date of birth
- 1964-12-27
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-427432
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-4992
- Coverage period
- 2023-08-01 to present
- Deductible
- $577.31 of $1,000.0058%
- Out-of-pocket maximum
- $441.15 of $2,000.0022%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 7874072318
- Network
- In network
- Rendering NPI
- 7874072318
- Location
- Tampa, FL · TIN 53-7384078
- Authorisation / referral
- none / REF478322
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 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $3,085.00 | $1,696.75 | $150.00 | $1,546.75 | Paid |
| 2 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $215.00 | $118.25 | $0.00 | $118.25 | Paid |
| 3 | 99284 rev 0450 | Emergency department visit, high severity | 25 | 1 | 1 | $1,764.00 | $970.20 | $0.00 | $970.20 | Paid |
| Totals | $5,064.00 | $2,785.20 | $150.00 | $2,635.20 | ||||||
- 1. R55 Syncope and collapseprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-387164
- 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-017546 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-24: NAVIGATE-HMO (HMO), effective 2023-08-01. | |
| Timely filing | Pass | Received 40 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 Canyon Regional Medical Center (7874072318). | |
| 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: Canyon Regional Medical Center2026-01-24 12:30
Follow-up for syncope and collapse. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-387164.pdf4 pages
Itemised statement totalling $5064.00 across 3 lines.
- Er reported_report_PA-387164.pdf2 pages
Emergency department record: triage acuity 4, 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
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.