CLM-2026-034042
Canyon Regional Medical Center, Emergency Medicine. Service 2026-07-19 at emergency room (POS 23). Received 2026-08-10.
Member
Resolved through the identity graph
- Member
- Natalie Singh
- Member ID
- UHC-94046-18
- Date of birth
- 1946-01-04
- Identity
- Verified3 records, confidence 0.93
- Claim record
- CLMCLM-407703
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-9124
- Coverage period
- 2024-05-01 to present
- Deductible
- $221.55 of $2,500.009%
- Out-of-pocket maximum
- $2,491.51 of $7,500.0033%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 7874072318
- Network
- In network
- Rendering NPI
- 7874072318
- Location
- Tampa, FL · TIN 53-7384078
- 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 | $1,070.00 | $588.50 | $150.00 | $438.50 | Paid |
| 2 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 2 | $1,603.00 | $881.65 | $0.00 | $881.65 | Paid |
| Totals | $2,673.00 | $1,470.15 | $150.00 | $1,320.15 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-794630
- 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-041137 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-07-19: MEDICARE-ADV-B (MA), effective 2024-05-01. | |
| Timely filing | Pass | Received 22 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 Canyon Regional Medical Center (7874072318). | |
| 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: Canyon Regional Medical Center2026-07-19 18:27
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-794630.pdf9 pages
Itemised statement totalling $2673.00 across 2 lines.
- Er reported_report_PA-794630.pdf2 pages
Emergency department record: triage acuity 4, chief complaint chest pain, unspecified.
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-2026-001830 | 2026-09-12 | Pinecrest Physical Therapy | $470.00 | 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.