CLM-2026-034238
Riverside Community Hospital, Emergency Medicine. Service 2025-08-10 at emergency room (POS 23). Received 2026-01-24.
Member
Resolved through the identity graph
- Member
- Diana Bell
- Member ID
- UHC-78952-19
- Date of birth
- 1962-10-11
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-417480
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-7679
- Coverage period
- 2024-12-01 to present
- Deductible
- $790.98 of $1,500.0053%
- Out-of-pocket maximum
- $655.95 of $6,000.0011%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 0 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 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $260.00 | $143.00 | — | — | DeniedCO29 |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 2 | $813.00 | $447.15 | — | — | DeniedCO29 |
| Totals | $1,073.00 | $590.15 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-209899
- 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-007094 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-08-10: NULL (PPO), effective 2024-12-01. | |
| Timely filing | Fail | CO29 | Received 167 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Hospital2025-08-10 12:31
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-01-24 04:59
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
- Itemized billitemized_PA-209899.pdf6 pages
Itemised statement totalling $1073.00 across 2 lines.
- Er reported_report_PA-209899.pdf5 pages
Emergency department record: triage acuity 2, chief complaint chest pain, unspecified.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 167 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Received after the timely-filing limit.