CLM-2026-029352
Canyon Regional Medical Center, Emergency Medicine. Service 2026-05-08 at emergency room (POS 23). Received 2026-06-20.
Member
Resolved through the identity graph
- Member
- Douglas Jensen
- Member ID
- UHC-04832-19
- Date of birth
- 1974-04-27
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-422156
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-0703
- Coverage period
- 2025-03-01 to present
- Deductible
- $363.74 of $1,000.0036%
- Out-of-pocket maximum
- $844.62 of $2,000.0042%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 0 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 | $864.00 | $475.20 | $150.00 | $325.20 | Paid |
| 2 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 2 | $2,231.00 | $1,227.05 | $0.00 | $1,227.05 | Paid |
| Totals | $3,095.00 | $1,702.25 | $150.00 | $1,552.25 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. R07.9 Chest pain, unspecified
- 3. R10.9 Unspecified abdominal pain
- Patient account
- PA-306529
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-022792 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-08: CHOICE-PLUS-PPO (PPO), effective 2025-03-01. | |
| Timely filing | Pass | Received 43 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 Center2026-05-08 18:14
Follow-up for pneumonia, unspecified organism. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-306529.pdf8 pages
Itemised statement totalling $3095.00 across 2 lines.
- Er reported_report_PA-306529.pdf3 pages
Emergency department record: triage acuity 3, 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 engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022382 | 2026-05-05 | Pinecrest GI Associates | $276.00 | Approved |
| CLM-2026-030306 | 2026-02-26 | Northgate Cardiovascular Associates | $722.00 | 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.