CLM-2026-029010
Canyon Regional Medical Center, Emergency Medicine. Service 2026-09-08 at emergency room (POS 23). Received 2026-09-14.
Member
Resolved through the identity graph
- Member
- Andrea Anderson
- Member ID
- UHC-88955-23
- Date of birth
- 1945-09-25
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-417228
- Relationship
- Spouse, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-5118
- Coverage period
- 2022-12-01 to 2026-03-16
- Deductible
- $825.68 of $1,500.0055%
- Out-of-pocket maximum
- $1,384.92 of $4,500.0031%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 7874072318
- Network
- In network
- Rendering NPI
- 7874072318
- Location
- Tampa, FL · TIN 53-7384078
- 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 | $1,333.00 | $733.15 | — | — | DeniedCO27 |
| Totals | $1,333.00 | $733.15 | — | — | ||||||
- 1. R55 Syncope and collapseprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-482518
- 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-018844 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-08 is after coverage terminated on 2026-03-16. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 6 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 Canyon Regional Medical Center (7874072318). | |
| 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: Canyon Regional Medical Center2026-09-08 09:18
Follow-up for syncope and collapse. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-14 06:26
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-09-14 14:06
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-482518.pdf5 pages
Itemised statement totalling $1333.00 across 1 line.
- Er reported_report_PA-482518.pdf3 pages
Emergency department record: triage acuity 2, chief complaint syncope and collapse.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-09-08 is after coverage terminated on 2026-03-16.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032186 | 2026-09-18 | Harbor Medical Group | $220.00 | Denied |
| CLM-2026-008397 | 2026-02-14 | Lakeside Physical Therapy | $126.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.