CLM-2026-029485
Cornerstone Regional Medical Center, Emergency Medicine. Service 2026-06-12 at emergency room (POS 23). Received 2026-06-23.
Member
Resolved through the identity graph
- Member
- Hannah Simmons
- Member ID
- UHC-61478-12
- Date of birth
- 1981-12-04
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-413059
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-9157
- Coverage period
- 2024-07-01 to present
- Deductible
- $892.85 of $1,000.0089%
- Out-of-pocket maximum
- $320.15 of $2,000.0016%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 1149569109
- Network
- In network
- Rendering NPI
- 1149569109
- Location
- Nashville, TN · TIN 45-8232836
- Authorisation / referral
- none / REF676279
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 | $776.00 | $426.80 | $350.00 | $76.80 | Paid |
| 2 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1,2 | $1,611.00 | $886.05 | $0.00 | $886.05 | Paid |
| Totals | $2,387.00 | $1,312.85 | $350.00 | $962.85 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. J18.9 Pneumonia, unspecified organism
- Patient account
- PA-379798
- 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-013348 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-06-12: NAVIGATE-HMO (HMO), effective 2024-07-01. | |
| Timely filing | Pass | Received 11 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 Cornerstone Regional Medical Center (1149569109). | |
| 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: Cornerstone Regional Medical Center2026-06-12 16:49
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-379798.pdf8 pages
Itemised statement totalling $2387.00 across 2 lines.
- Er reported_report_PA-379798.pdf5 pages
Emergency department record: triage acuity 4, chief complaint chest pain, unspecified.
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-2026-000696 | 2026-08-13 | Sunrise Cardiovascular Associates | $307.00 | 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.