CLM-2026-031421
Pinecrest Regional Medical Center, Emergency Medicine. Service 2026-02-04 at emergency room (POS 23). Received 2026-03-20.
Member
Resolved through the identity graph
- Member
- Sandra Reyes
- Member ID
- UHC-36461-68
- Date of birth
- 1982-05-09
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-420377
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-4425
- Coverage period
- 2024-10-01 to present
- Deductible
- $2,101.08 of $3,500.0060%
- Out-of-pocket maximum
- $6,852.66 of $14,000.0049%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 2061946325
- Network
- In network
- Rendering NPI
- 2061946325
- Location
- Denver, CO · TIN 60-4146079
- 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 | $1,077.00 | $592.35 | $250.00 | $342.35 | Paid |
| Totals | $1,077.00 | $592.35 | $250.00 | $342.35 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- Patient account
- PA-166397
- 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-018376 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-04: NULL (PPO), effective 2024-10-01. | |
| Timely filing | Pass | Received 44 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 Pinecrest Regional Medical Center (2061946325). | |
| 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: Pinecrest Regional Medical Center2026-02-04 13:20
Patient seen for pneumonia, unspecified organism.
Attachments
Documents received with the claim
- Itemized billitemized_PA-166397.pdf4 pages
Itemised statement totalling $1077.00 across 1 line.
- Er reported_report_PA-166397.pdf2 pages
Emergency department record: triage acuity 2, 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-2026-004887 | 2026-09-24 | Valley Skin Care Associates | $804.00 | 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.