CLM-2026-033831
Riverside Community Hospital, Emergency Medicine. Service 2026-08-10 at emergency room (POS 23). Received 2026-08-31.
Member
Resolved through the identity graph
- Member
- Patricia Andrews
- Member ID
- UHC-97038-28
- Date of birth
- 1996-05-07
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-409031
- Relationship
- Child, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-4147
- Coverage period
- 2022-07-01 to present
- Deductible
- $159.58 of $500.0032%
- Out-of-pocket maximum
- $253.78 of $1,000.0025%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 12 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 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $898.00 | $493.90 | $250.00 | $243.90 | Paid |
| 2 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $2,500.00 | $1,375.00 | $0.00 | $1,375.00 | Paid |
| Totals | $3,398.00 | $1,868.90 | $250.00 | $1,618.90 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- Patient account
- PA-569952
- 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-013173 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-10: MEDICARE-ADV-A (MA), effective 2022-07-01. | |
| Timely filing | Pass | Received 21 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 Hospital2026-08-10 16:24
Established patient presents with pneumonia, unspecified organism; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-569952.pdf4 pages
Itemised statement totalling $3398.00 across 2 lines.
- Er reported_report_PA-569952.pdf6 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
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.