CLM-2026-030963
Meadow Regional Medical Center, Emergency Medicine. Service 2026-06-03 at emergency room (POS 23). Received 2026-06-06.
Member
Resolved through the identity graph
- Member
- Michael Jordan
- Member ID
- UHC-94325-83
- Date of birth
- 2000-11-24
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-406544
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group NULL
- Coverage period
- 2022-11-01 to present
- Deductible
- $1,401.89 of $2,500.0056%
- Out-of-pocket maximum
- $4,800.27 of $10,000.0048%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 1905050427
- Network
- In network
- Rendering NPI
- 1905050427
- Location
- Dallas, TX · TIN 71-2312931
- Authorisation / referral
- none / REF339929
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 | $1,548.00 | $851.40 | $150.00 | $701.40 | Paid |
| 2 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $188.00 | $103.40 | $0.00 | $103.40 | Paid |
| 3 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $769.00 | $422.95 | $0.00 | $422.95 | Paid |
| Totals | $2,505.00 | $1,377.75 | $150.00 | $1,227.75 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- Patient account
- PA-162383
- 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-020796 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-03: NAVIGATE-HMO (HMO), effective 2022-11-01. | |
| Timely filing | Pass | Received 3 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 Meadow Regional Medical Center (1905050427). | |
| 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: Meadow Regional Medical Center2026-06-03 10:45
Patient seen for pneumonia, unspecified organism.
Attachments
Documents received with the claim
- Itemized billitemized_PA-162383.pdf9 pages
Itemised statement totalling $2505.00 across 3 lines.
- Er reported_report_PA-162383.pdf2 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
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.