CLM-2026-028917
Riverside Community Hospital, Emergency Medicine. Service 2026-08-15 at emergency room (POS 23). Received 2026-09-21.
Member
Resolved through the identity graph
- Member
- Albert Mendez
- Member ID
- UHC-76989-44
- Date of birth
- 1972-10-21
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-413214
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6807
- Coverage period
- 2022-12-01 to present
- Deductible
- $219.77 of $1,000.0022%
- Out-of-pocket maximum
- $170.42 of $2,000.009%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 1928747868
- Network
- In network
- Rendering NPI
- 1928747868
- Location
- Mesa, AZ · TIN 30-6800456
- 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 | $1,591.00 | $875.05 | $350.00 | $525.05 | Paid |
| Totals | $1,591.00 | $875.05 | $350.00 | $525.05 | ||||||
- 1. R55 Syncope and collapseprincipal
- Patient account
- PA-222864
- 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-034354 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-08-15: - (PPO), effective 2022-12-01. | |
| Timely filing | Pass | Received 37 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 Riverside Community Hospital (1928747868). | |
| 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: Riverside Community Hospital2026-08-15 18:00
Patient seen for syncope and collapse.
Attachments
Documents received with the claim
- Itemized billitemized_PA-222864.pdf6 pages
Itemised statement totalling $1591.00 across 1 line.
- Er reported_report_PA-222864.pdf5 pages
Emergency department record: triage acuity 2, 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-000202 | 2026-05-04 | Sunrise Cardiovascular Associates | $4,961.00 | 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.