CLM-2026-027811
Meadow Regional Medical Center, Emergency Medicine. Service 2026-07-30 at emergency room (POS 23). Received 2026-08-12.
Member
Resolved through the identity graph
- Member
- Andrea Le
- Member ID
- UHC-70351-27
- Date of birth
- 1957-02-16
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-417588
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-9179
- Coverage period
- 2022-06-01 to present
- Deductible
- $1,331.93 of $1,500.0089%
- Out-of-pocket maximum
- $756.96 of $3,000.0025%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 1905050427
- Network
- In network
- Rendering NPI
- 1905050427
- Location
- Dallas, TX · TIN 71-2312931
- 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 | $1,644.00 | $904.20 | $150.00 | $754.20 | Paid |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $776.00 | $426.80 | $0.00 | $426.80 | Paid |
| 3 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $2,251.00 | $1,238.05 | $0.00 | $1,238.05 | Paid |
| Totals | $4,671.00 | $2,569.05 | $150.00 | $2,419.05 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-308989
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-028633 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-30: CHOICE-PLUS-PPO (PPO), effective 2022-06-01. | |
| Timely filing | Pass | Received 13 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 Meadow Regional Medical Center (1905050427). | |
| 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: Meadow Regional Medical Center2026-07-30 14:28
Patient seen for pneumonia, unspecified organism.
Attachments
Documents received with the claim
- Itemized billitemized_PA-308989.pdf4 pages
Itemised statement totalling $4671.00 across 3 lines.
- Er reported_report_PA-308989.pdf5 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 12:44Clean 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.