CLM-2026-034283
Pinecrest Regional Medical Center, Emergency Medicine. Service 2026-03-05 at emergency room (POS 23). Received 2026-03-20.
Member
Resolved through the identity graph
- Member
- Mike Simmons
- Member ID
- UHC-55383-31
- Date of birth
- 1994-02-27
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-416737
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-4135
- Coverage period
- 2021-11-01 to present
- Deductible
- $322.47 of $500.0064%
- Out-of-pocket maximum
- $257.96 of $1,000.0026%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 1000861728
- Network
- Out of network
- Rendering NPI
- 1000861728
- Location
- Austin, TX · TIN 41-0807117
- 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 | $205.00 | $92.25 | $92.25 | $0.00 | Paid |
| Totals | $205.00 | $92.25 | $92.25 | $0.00 | ||||||
- 1. R55 Syncope and collapseprincipal
- Patient account
- PA-535417
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000648 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-05: MEDICARE-ADV-B (MA), effective 2021-11-01. | |
| Timely filing | Pass | Received 15 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Pinecrest Regional Medical Center2026-03-05 15:43
Patient seen for syncope and collapse.
Attachments
Documents received with the claim
- Itemized billitemized_PA-535417.pdf5 pages
Itemised statement totalling $205.00 across 1 line.
- Er reported_report_PA-535417.pdf3 pages
Emergency department record: triage acuity 3, 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 engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004016 | 2026-07-26 | Sunrise Cardiovascular Associates | $356.00 | Approved |
| CLM-2026-032854 | 2026-02-26 | Desert Internal Medicine Associates | $94.00 | Approved |
| CLM-2026-008390 | 2025-12-12 | Evergreen Diagnostic Imaging | $4,855.00 | 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.