CLM-2026-029520
Pinecrest Regional Medical Center, Emergency Medicine. Service 2026-07-26 at emergency room (POS 23). Received 2026-09-04.
Member
Resolved through the identity graph
- Member
- Jereym Rios
- Member ID
- UHC-43577-47
- Date of birth
- 1938-12-24
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-428420
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4802
- Coverage period
- 2022-02-01 to 2026-08-08
- Deductible
- $442.75 of $500.0089%
- Out-of-pocket maximum
- $38.73 of $1,500.003%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 2061946325
- Network
- In network
- Rendering NPI
- 2061946325
- Location
- Denver, CO · TIN 60-4146079
- 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 | $1,276.00 | $701.80 | $350.00 | $351.80 | Paid |
| 2 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $2,125.00 | $1,168.75 | $0.00 | $1,168.75 | Paid |
| 3 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $254.00 | $139.70 | $0.00 | $139.70 | Paid |
| Totals | $3,655.00 | $2,010.25 | $350.00 | $1,660.25 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-997260
- 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-030529 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-26: SELECT-EPO (EPO), effective 2022-02-01, terms 2026-08-08. | |
| Timely filing | Pass | Received 40 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 Pinecrest Regional Medical Center (2061946325). | |
| 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: Pinecrest Regional Medical Center2026-07-26 18:20
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-997260.pdf4 pages
Itemised statement totalling $3655.00 across 3 lines.
- Er reported_report_PA-997260.pdf4 pages
Emergency department record: triage acuity 2, chief complaint unspecified abdominal pain.
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
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.