CLM-2026-031023
Desert Regional Medical Center, Emergency Medicine. Service 2026-07-31 at emergency room (POS 23). Received 2026-09-14.
Member
Resolved through the identity graph
- Member
- Ralph Weaver
- Member ID
- UHC-96928-89
- Date of birth
- 1945-03-16
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-412690
- Relationship
- Child, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8750
- Coverage period
- 2022-11-01 to 2026-01-21
- Deductible
- $320.64 of $500.0064%
- Out-of-pocket maximum
- $85.79 of $2,000.004%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 7 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 / 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 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $223.00 | $122.65 | — | — | DeniedCO27 |
| Totals | $223.00 | $122.65 | — | — | ||||||
- 1. R55 Syncope and collapseprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-728330
- 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 | Pass | Attached to MBR-011373 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-31 is after coverage terminated on 2026-01-21. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 45 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 Center2026-07-31 18:45
Follow-up for syncope and collapse. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-14 01:10
Attachments
Documents received with the claim
- Itemized billitemized_PA-728330.pdf9 pages
Itemised statement totalling $223.00 across 1 line.
- Er reported_report_PA-728330.pdf2 pages
Emergency department record: triage acuity 3, chief complaint syncope and collapse.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-07-31 is after coverage terminated on 2026-01-21.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-013110 | 2026-02-19 | Meadow Diagnostic Imaging | $4,405.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.