CLM-2026-001782
Heritage Community Hospital, Emergency Medicine. Service 2026-01-25 at outpatient hospital (POS 22). Received 2026-03-04.
Member
Resolved through the identity graph
- Member
- Lawrence Gutierrez
- Member ID
- UHC-20067-85
- Date of birth
- 1960-06-19
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-425345
- Relationship
- Child, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-3372
- Coverage period
- 2022-08-01 to 2026-01-22
- Deductible
- $4.47 of $1,500.000%
- Out-of-pocket maximum
- $169.35 of $4,500.004%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 5 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
- PA2025700751 / 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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,453.00 | $1,349.15 | — | — | DeniedCO27 |
| Totals | $2,453.00 | $1,349.15 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- 3. J18.9 Pneumonia, unspecified organism
- Patient account
- PA-781272
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-017425 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-01-25 is after coverage terminated on 2026-01-22. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 38 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025700751 on file for 70553. | |
| Provider network | Pass | In-network provider Heritage Community Hospital (5375971814). | |
| Medical necessity | Review | CO50 | 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity. Not medically necessary per payer policy |
| 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 Hospital2026-01-25 18:17
Patient seen for encounter for general adult medical examination without abnormal findings.
- SystemSystem: Claims system2026-03-04 06:03
Attachments
Documents received with the claim
- Prior auth letterPA2025700751_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-01-25 to 2026-04-25.
- Itemized billitemized_PA-781272.pdf3 pages
Itemised statement totalling $2453.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-01-25 is after coverage terminated on 2026-01-22. Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
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.