CLM-2026-032346
Desert Regional Medical Center, Emergency Medicine. Service 2026-02-17 at emergency room (POS 23). Received 2026-03-25.
Member
Resolved through the identity graph
- Member
- Joshua Dominguez
- Member ID
- UHC-51478-26
- Date of birth
- 1988-11-04
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-422837
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-9596
- Coverage period
- 2022-08-01 to present
- Deductible
- $359.56 of $1,500.0024%
- Out-of-pocket maximum
- $1,398.78 of $4,500.0031%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- 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 / 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 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,207.00 | $663.85 | — | — | Review |
| Totals | $1,207.00 | $663.85 | — | — | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. R10.9 Unspecified abdominal pain
- 3. R55 Syncope and collapse
- Patient account
- PA-713935
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-021860 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-17: SELECT-EPO (EPO), effective 2022-08-01. | |
| Timely filing | Pass | Received 36 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 | Review | CO16 | Documentation incomplete: “Follow-up for pneumonia, unspecified organism. Plan discussed, medications reconciled. Not”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Desert Regional Medical Center2026-02-17 17:42
Follow-up for pneumonia, unspecified organism. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-03-25 06:45
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-03-25 12:54
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-713935.pdf5 pages
Itemised statement totalling $1207.00 across 1 line.
- Er reported_report_PA-713935.pdf5 pages
Emergency department record: triage acuity 3, chief complaint pneumonia, unspecified organism.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Completeness: Documentation incomplete: “Follow-up for pneumonia, unspecified organism. Plan discussed, medications reconciled. Not”.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.