CLM-2026-029769
Canyon Regional Medical Center, Emergency Medicine. Service 2026-06-25 at emergency room (POS 23). Received 2026-07-05.
Member
Resolved through the identity graph
- Member
- Fatima Boyd
- Member ID
- UHC-18372-48
- Date of birth
- 1985-07-28
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-414020
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-5746
- Coverage period
- 2023-06-01 to present
- Deductible
- $619.15 of $1,500.0041%
- Out-of-pocket maximum
- $1,771.31 of $6,000.0030%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 4 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 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,363.00 | $749.65 | — | — | PendedIDQ |
| Totals | $1,363.00 | $749.65 | — | — | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-700380
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-004195; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-06-25: MEDICARE-ADV-B (MA), effective 2023-06-01. | |
| Timely filing | Pass | Received 10 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 Center2026-06-25 10:49
Established patient presents with pneumonia, unspecified organism; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-700380.pdf7 pages
Itemised statement totalling $1363.00 across 1 line.
- Er reported_report_PA-700380.pdf5 pages
Emergency department record: triage acuity 4, 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-004195; payment withheld until the identity is confirmed.
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.