CLM-2026-030717
Riverside Community Hospital, Emergency Medicine. Service 2026-06-25 at emergency room (POS 23). Received 2026-07-25.
Member
Resolved through the identity graph
- Member
- Evelyn Vargas
- Member ID
- UHC-61305-53
- Date of birth
- 1995-06-15
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-431619
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-9192
- Coverage period
- 2023-04-01 to present
- Deductible
- $513.48 of $1,500.0034%
- Out-of-pocket maximum
- $1,910.35 of $6,000.0032%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 1928747868
- Network
- In network
- Rendering NPI
- 1928747868
- Location
- Mesa, AZ · TIN 30-6800456
- 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 | $1,029.00 | $565.95 | $350.00 | $215.95 | Paid |
| 2 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $150.00 | $82.50 | $0.00 | $82.50 | Paid |
| Totals | $1,179.00 | $648.45 | $350.00 | $298.45 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- Patient account
- PA-986636
- 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-039590 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-25: CHOICE-PLUS-PPO (PPO), effective 2023-04-01. | |
| Timely filing | Pass | Received 30 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 Riverside Community Hospital (1928747868). | |
| 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: Riverside Community Hospital2026-06-25 09:21
Follow-up for pneumonia, unspecified organism. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-986636.pdf2 pages
Itemised statement totalling $1179.00 across 2 lines.
- Er reported_report_PA-986636.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-2026-005804 | 2026-09-10 | Lakeside Physical Therapy | $508.00 | 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.