CLM-2026-030984
Desert Regional Medical Center, Emergency Medicine. Service 2026-06-06 at emergency room (POS 23). Received 2026-06-22.
Member
Resolved through the identity graph
- Member
- Carl Rios
- Member ID
- UHC-20090-95
- Date of birth
- 2007-05-20
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-432062
- Relationship
- Child, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9649
- Coverage period
- 2022-03-01 to present
- Deductible
- $94.84 of $1,000.009%
- Out-of-pocket maximum
- $1,849.08 of $4,000.0046%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 8317237419
- Network
- In network
- Rendering NPI
- 8317237419
- Location
- Austin, TX · TIN 55-6992539
- Authorisation / referral
- none / REF260679
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 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $2,471.00 | $1,359.05 | $150.00 | $1,209.05 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $182.00 | $100.10 | $0.00 | $100.10 | Paid |
| Totals | $2,653.00 | $1,459.15 | $150.00 | $1,309.15 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- Patient account
- PA-618847
- 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-013839 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-06: CORE-HMO (HMO), effective 2022-03-01. | |
| Timely filing | Pass | Received 16 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 Desert Regional Medical Center (8317237419). | |
| 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: Desert Regional Medical Center2026-06-06 17:08
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-618847.pdf2 pages
Itemised statement totalling $2653.00 across 2 lines.
- Er reported_report_PA-618847.pdf6 pages
Emergency department record: triage acuity 3, 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-2026-032973 | 2026-07-24 | Heritage Medical Group | $200.00 | Denied |
| CLM-2026-032972 | 2026-07-24 | Heritage Medical Group | $200.00 | 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.