CLM-2026-034344
Riverside Regional Medical Center, Emergency Medicine. Service 2026-01-26 at emergency room (POS 23). Received 2026-02-11.
Member
Resolved through the identity graph
- Member
- Ralph Tran
- Member ID
- UHC-19577-66
- Date of birth
- 1938-12-26
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-428813
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-9695
- Coverage period
- 2021-04-01 to present
- Deductible
- $198.64 of $500.0040%
- Out-of-pocket maximum
- $859.47 of $2,000.0043%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 5185579187
- Network
- Out of network
- Rendering NPI
- 5185579187
- Location
- Tempe, AZ · TIN 24-5730797
- 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 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,405.00 | $772.75 | — | — | Review |
| 2 | 96374 rev 0260 | IV push, single drug | 25 | 1 | 1 | $144.00 | $79.20 | — | — | Review |
| 3 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 2 | $141.00 | $77.55 | — | — | Review |
| Totals | $1,690.00 | $929.50 | — | — | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- Patient account
- PA-789943
- 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-002126 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-26: SELECT-EPO (EPO), effective 2021-04-01. | |
| Timely filing | Pass | Received 16 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 | Review | NET | Out-of-network emergency visit. Payable at the in-network level if the prudent-layperson standard is met; review the ED record. Out-of-network provider |
| 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 Regional Medical Center2026-01-26 09:01
Patient seen for pneumonia, unspecified organism. Patient presented to the nearest emergency department with acute symptoms; care could not safely be delayed to reach an in-network facility.
- SystemSystem: Claims system2026-02-11 03:42
Out-of-network emergency visit. Emergency services are payable at the in-network level when the prudent-layperson standard is met.
Attachments
Documents received with the claim
- Itemized billitemized_PA-789943.pdf3 pages
Itemised statement totalling $1690.00 across 3 lines.
- Er reported_report_PA-789943.pdf2 pages
Emergency department record: triage acuity 3, chief complaint pneumonia, unspecified organism.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Provider network: Out-of-network emergency visit. Payable at the in-network level if the prudent-layperson standard is met; review the ED record.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031555 | 2025-11-27 | Unity Counseling Center | $560.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Emergency: payable at in-network level.