CLM-2026-029344
Canyon Regional Medical Center, Emergency Medicine. Service 2026-05-05 at emergency room (POS 23). Received 2026-05-30.
Member
Resolved through the identity graph
- Member
- Tyler Gray
- Member ID
- UHC-40253-88
- Date of birth
- 2005-10-24
- Identity
- Verified5 records, confidence 0.93
- Claim record
- CLMCLM-414935
- Relationship
- Child, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-0578
- Coverage period
- 2022-03-01 to present
- Deductible
- $145.74 of $500.0029%
- Out-of-pocket maximum
- $772.25 of $2,000.0039%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 14 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 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $757.00 | $416.35 | $350.00 | $66.35 | Paid |
| Totals | $757.00 | $416.35 | $350.00 | $66.35 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-813909
- 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-030062 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-05-05: SELECT-EPO (EPO), effective 2022-03-01. | |
| Timely filing | Pass | Received 25 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 Center2026-05-05 16:00
Established patient presents with pneumonia, unspecified organism; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-813909.pdf6 pages
Itemised statement totalling $757.00 across 1 line.
- Er reported_report_PA-813909.pdf2 pages
Emergency department record: triage acuity 2, 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 engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-013736 | 2026-09-12 | Lakeside Digestive Health Center | $1,678.00 | Approved |
| CLM-2026-019457 | 2026-07-28 | Sunrise Cardiovascular Associates | $1,845.00 | Approved |
| CLM-2026-015255 | 2026-04-09 | Desert Regional Medical Center | $633.00 | Denied |
| CLM-2026-003196 | 2026-04-29 | Mesa Internal Medicine Associates | $212.00 | Approved |
| CLM-2026-015254 | 2026-04-09 | Desert Regional Medical Center | $633.00 | 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.