CLM-2026-001736
Heritage Community Hospital, Emergency Medicine. Service 2026-04-15 at emergency room (POS 23). Received 2026-05-09.
Member
Resolved through the identity graph
- Member
- Fatima Myers
- Member ID
- UHC-02930-28
- Date of birth
- 1948-02-05
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-415297
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-8726
- Coverage period
- 2024-01-01 to 2026-02-11
- Deductible
- $663.48 of $1,500.0044%
- Out-of-pocket maximum
- $153.61 of $6,000.003%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 5375971814
- Network
- In network
- Rendering NPI
- 5375971814
- Location
- Atlanta, GA · TIN 80-9992257
- 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $193.00 | $106.15 | — | — | DeniedCO27 |
| Totals | $193.00 | $106.15 | — | — | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. R55 Syncope and collapse
- Patient account
- PA-302067
- 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-029884 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-15 is after coverage terminated on 2026-02-11. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 24 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 (5375971814). | |
| 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 Hospital2026-04-15 13:30
Follow-up for pneumonia, unspecified organism. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-05-09 04:40
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-05-09 14:51
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-302067.pdf3 pages
Itemised statement totalling $193.00 across 1 line.
- Er reported_report_PA-302067.pdf4 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 engineDenied2026-10-22 12:44Eligibility: Date of service 2026-04-15 is after coverage terminated on 2026-02-11.
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
Service after coverage termination.