CLM-2026-027625
Pinecrest Regional Medical Center, Emergency Medicine. Service 2026-04-14 at emergency room (POS 23). Received 2026-05-16.
Member
Resolved through the identity graph
- Member
- Dennis Ray
- Member ID
- UHC-11585-25
- Date of birth
- 1961-07-12
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-420713
- Relationship
- Spouse, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-0529
- Coverage period
- 2024-12-01 to present
- Deductible
- $1,175.92 of $2,500.0047%
- Out-of-pocket maximum
- $2,231.72 of $7,500.0030%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 1000861728
- Network
- Out of network
- Rendering NPI
- 1000861728
- Location
- Austin, TX · TIN 41-0807117
- 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 | $1,485.00 | $668.25 | — | — | Review |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $1,009.00 | $454.05 | — | — | Review |
| Totals | $2,494.00 | $1,122.30 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-233952
- Frequency code
- 7 (replacement)
- Accident
- Yes
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 12 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-021384 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-14: OPTIONS-PPO (PPO), effective 2024-12-01. | |
| Timely filing | Pass | Received 32 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Replacement claim | Review | REPL | Frequency code 7 replaces CLM-2026-027624; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission |
| 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: Pinecrest Regional Medical Center2026-04-14 17:38
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
- SystemSystem: Claims system2026-05-16 06:24
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
Attachments
Documents received with the claim
- Itemized billitemized_PA-233952.pdf7 pages
Itemised statement totalling $2494.00 across 2 lines.
- Er reported_report_PA-233952.pdf6 pages
Emergency department record: triage acuity 3, chief complaint unspecified abdominal pain.
- Corrected claimcorrected_CLM-2026-027624.pdf1 page
Provider cover letter requesting replacement of CLM-2026-027624.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Replacement claim: Frequency code 7 replaces CLM-2026-027624; the original must be voided when this adjudicates. Provider 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-2026-028344 | 2026-06-01 | Evergreen Dermatology Clinic | $950.00 | Approved |
| CLM-2026-020504 | 2026-06-05 | Canyon Internal Medicine Associates | $186.00 | Approved |
| CLM-2026-027624 | 2026-04-14 | Pinecrest Regional Medical Center | $2,494.00 | Approved |
| CLM-2026-023035 | 2026-03-01 | Sunrise Orthopedic Specialists | $42,280.00 | Needs review |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Replacement claim supersedes the original.