CLM-2026-032827
Riverside Community Hospital, Emergency Medicine. Service 2026-02-16 at emergency room (POS 23). Received 2026-03-02.
Member
Resolved through the identity graph
- Member
- Kevin Stevens
- Member ID
- UHC-74291-02
- Date of birth
- 1947-11-12
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-403592
- Relationship
- Spouse, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3092
- Coverage period
- 2023-08-01 to present
- Deductible
- $392.59 of $1,000.0039%
- Out-of-pocket maximum
- $1,387.60 of $3,000.0046%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 1928747868
- Network
- In network
- Rendering NPI
- 1928747868
- Location
- Mesa, AZ · TIN 30-6800456
- 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 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $2,634.00 | $1,448.70 | $350.00 | $1,098.70 | Paid |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $1,036.00 | $569.80 | $0.00 | $569.80 | Paid |
| Totals | $3,670.00 | $2,018.50 | $350.00 | $1,668.50 | ||||||
- 1. R55 Syncope and collapseprincipal
- Patient account
- PA-451840
- 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-016838 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-16: CHOICE-PLUS-PPO (PPO), effective 2023-08-01. | |
| Timely filing | Pass | Received 14 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 Riverside Community Hospital (1928747868). | |
| 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: Riverside Community Hospital2026-02-16 15:04
Established patient presents with syncope and collapse; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-451840.pdf3 pages
Itemised statement totalling $3670.00 across 2 lines.
- Er reported_report_PA-451840.pdf6 pages
Emergency department record: triage acuity 2, chief complaint syncope and collapse.
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.