CLM-2026-029325
Riverside Regional Medical Center, Emergency Medicine. Service 2026-06-17 at emergency room (POS 23). Received 2026-07-14.
Member
Resolved through the identity graph
- Member
- Patricia Hernandez
- Member ID
- UHC-44396-50
- Date of birth
- 1977-03-19
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-422303
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1902
- Coverage period
- 2025-01-01 to present
- Deductible
- $1,648.37 of $2,500.0066%
- Out-of-pocket maximum
- $1,398.99 of $7,500.0019%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 5185579187
- Network
- Out of network
- Rendering NPI
- 5185579187
- Location
- Tempe, AZ · TIN 24-5730797
- 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 | $1,416.00 | $637.20 | — | — | PendedIDQ |
| Totals | $1,416.00 | $637.20 | — | — | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- Patient account
- PA-886506
- 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-002956; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-06-17: NULL (PPO), effective 2025-01-01. | |
| Timely filing | Pass | Received 27 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 | 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: Riverside Regional Medical Center2026-06-17 09:08
Patient seen for pneumonia, unspecified organism.
Attachments
Documents received with the claim
- Itemized billitemized_PA-886506.pdf4 pages
Itemised statement totalling $1416.00 across 1 line.
- Er reported_report_PA-886506.pdf2 pages
Emergency department record: triage acuity 3, chief complaint pneumonia, unspecified organism.
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-002956; payment withheld until the identity is confirmed. 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
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.