CLM-2026-027586
Mesa Regional Medical Center, Emergency Medicine. Service 2025-12-25 at emergency room (POS 23). Received 2026-01-25.
Member
Resolved through the identity graph
- Member
- Charles Hall
- Member ID
- UHC-31175-80
- Date of birth
- 1983-05-04
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-400107
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-8895
- Coverage period
- 2024-02-01 to 2026-06-05
- Deductible
- $2,117.59 of $2,500.0085%
- Out-of-pocket maximum
- $2,996.03 of $7,500.0040%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 21 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 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,381.00 | $621.45 | $150.00 | $471.45 | Paid |
| 2 | 96374 rev 0260 | IV push, single drug | — | 1 | 2 | $143.00 | $64.35 | $0.00 | $64.35 | Paid |
| Totals | $1,524.00 | $685.80 | $150.00 | $535.80 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. J18.9 Pneumonia, unspecified organism
- 3. R10.9 Unspecified abdominal pain
- Patient account
- PA-672036
- Frequency code
- 1 (original)
- Accident
- Yes
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-007606 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-25: OPTIONS-PPO (PPO), effective 2024-02-01, terms 2026-06-05. | |
| Timely filing | Pass | Received 31 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 Center2025-12-25 09:51
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-672036.pdf9 pages
Itemised statement totalling $1524.00 across 2 lines.
- Er reported_report_PA-672036.pdf2 pages
Emergency department record: triage acuity 4, 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 engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-013339 | 2026-03-29 | Unity Primary Care Associates | $216.00 | Approved |
| CLM-2026-014056 | 2026-02-28 | Meadow Medical Group | $249.00 | 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.