CLM-2026-000117
Heritage Community Hospital, Emergency Medicine. Service 2026-01-21 at emergency room (POS 23). Received 2026-01-28.
Member
Resolved through the identity graph
- Member
- Carlos Campbell
- Member ID
- UHC-89227-34
- Date of birth
- 1961-06-18
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-422045
- Relationship
- Child, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9054
- Coverage period
- 2024-06-01 to present
- Deductible
- $132.17 of $500.0026%
- Out-of-pocket maximum
- $307.45 of $2,000.0015%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 2102151364
- Network
- In network
- Rendering NPI
- 2102151364
- Location
- Tampa, FL · TIN 69-1549407
- Authorisation / referral
- none / REF497942
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 | $1,075.00 | $591.25 | $350.00 | $241.25 | Paid |
| 2 | 96374 rev 0260 | IV push, single drug | — | 1 | 2 | $193.00 | $106.15 | $0.00 | $106.15 | Paid |
| 3 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 2 | $260.00 | $143.00 | $0.00 | $143.00 | Paid |
| Totals | $1,528.00 | $840.40 | $350.00 | $490.40 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- Patient account
- PA-837537
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-008494 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-01-21: CORE-HMO (HMO), effective 2024-06-01. | |
| Timely filing | Pass | Received 7 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 Heritage Community Hospital (2102151364). | |
| 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: Heritage Community Hospital2026-01-21 16:01
Patient seen for pneumonia, unspecified organism.
Attachments
Documents received with the claim
- Itemized billitemized_PA-837537.pdf4 pages
Itemised statement totalling $1528.00 across 3 lines.
- Er reported_report_PA-837537.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 engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007138 | 2026-06-17 | Valley Cardiovascular Associates | $647.00 | Approved |
| CLM-2026-006912 | 2026-04-04 | Valley Heart Institute | $226.00 | Approved |
| CLM-2026-031894 | 2026-02-04 | Lakeside Medical Group | $190.00 | Denied |
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.