CLM-2026-028057
Desert Regional Medical Center, Emergency Medicine. Service 2026-04-24 at emergency room (POS 23). Received 2026-05-05.
Member
Resolved through the identity graph
- Member
- Olivia Ruiz
- Member ID
- none on golden record
- Date of birth
- 1961-01-18
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-414789
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- NAVIGATE-HMO HMO group GRP-8947
- Coverage period
- 2024-05-01 to present
- Deductible
- $153.26 of $2,500.006%
- Out-of-pocket maximum
- $2,357.68 of $10,000.0024%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 8317237419
- Network
- In network
- Rendering NPI
- 8317237419
- Location
- Austin, TX · TIN 55-6992539
- Authorisation / referral
- none / REF623934
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 | $858.00 | $471.90 | — | — | PendedIDQ |
| Totals | $858.00 | $471.90 | — | — | ||||||
- 1. S93.401A Sprain of unspecified ligament of right ankle, initial encounterprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-223625
- Frequency code
- 1 (original)
- Accident
- Yes
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-001149; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-04-24: NAVIGATE-HMO (HMO), effective 2024-05-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 11 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 Desert Regional Medical Center (8317237419). | |
| 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: Desert Regional Medical Center2026-04-24 15:13
Patient seen for sprain of unspecified ligament of right ankle, initial encounter.
Attachments
Documents received with the claim
- Itemized billitemized_PA-223625.pdf9 pages
Itemised statement totalling $858.00 across 1 line.
- Er reported_report_PA-223625.pdf3 pages
Emergency department record: triage acuity 4, chief complaint sprain of unspecified ligament of right ankle, initial encounter.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-001149; payment withheld until the identity is confirmed. Eligibility: Active on 2026-04-24: NAVIGATE-HMO (HMO), effective 2024-05-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
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
Clean claim, priced at contract rate.