Claims workbench/CLM-2026-004410

Institutional claim · UB-04 · EDI 837I

CLM-2026-004410

Heritage Community Hospital, Emergency Medicine. Service 2026-06-26 at emergency room (POS 23). Received 2026-08-13.

Needs review

Billed

$4,860.00

3 lines

Allowed

$2,673.00

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Review

DUP

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Noah West
Member ID: UHC-54131-68
Date of birth: 2008-12-14
Identity: Verified4 records, confidence 0.97
Claim record: CLMCLM-401195
Relationship: Self, Denver, CO

Coverage and accumulators

Found by member ID

Plan: SELECT-EPO EPO group GRP-2799
Coverage period: 2022-08-01 to present
Deductible: $448.41 of $1,000.0045%
Out-of-pocket maximum: $1,331.69 of $3,000.0044%
Copays: office $20.00, specialist $75.00, emergency $350.00
Physical therapy visits: 14 of 20 used

Provider

Billing and rendering

Billing provider: Heritage Community Hospital
Emergency Medicine · taxonomy 207P00000X
NPI: 5375971814
Network: In network
Rendering NPI: 1905050427 (Meadow Regional Medical Center)
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	99284 rev 0450	Emergency department visit, high severity	—	1	1	$1,346.00	$740.30	—	—	Review
2	99283 rev 0450	Emergency department visit, moderate severity	—	1	2	$803.00	$441.65	—	—	Review
3	99285 rev 0450	Emergency department visit, high severity with threat to life	—	1	1,2	$2,711.00	$1,491.05	—	—	Review
Totals						$4,860.00	$2,673.00	—	—

Diagnoses (ICD-10-CM)

1. J18.9 Pneumonia, unspecified organismprincipal
2. R07.9 Chest pain, unspecified
3. S93.401A Sprain of unspecified ligament of right ankle, initial encounter

Claim header

Patient account: PA-724166
Frequency code: 1 (original)
Accident: Yes
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-026836 (verified, link confidence 0.97).
Eligibility	Pass		Active on 2026-06-26: SELECT-EPO (EPO), effective 2022-08-01.
Timely filing	Pass		Received 48 days after service (limit 90).
Duplicate check	Review	DUP	Same member, date of service and procedures as CLM-2026-004409, billed by a different provider. Possible duplicate
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.

Evaluated 2026-10-22 12:44 under policy version 1. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Heritage Community Hospital2026-06-26 18:27
Established patient presents with pneumonia, unspecified organism; symptoms reviewed and vitals within expected range. Patient was seen earlier the same day by another provider for an unrelated complaint.
SystemSystem: Claims system2026-08-13 01:01
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-08-13 08:03
Reviewed with the member's history on file. Holding for the items listed above.

Attachments

Documents received with the claim

Itemized billitemized_PA-724166.pdf3 pages
Itemised statement totalling $4860.00 across 3 lines.
Er reported_report_PA-724166.pdf4 pages
Emergency department record: triage acuity 2, chief complaint pneumonia, unspecified organism.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-22 12:44
Duplicate check: Same member, date of service and procedures as CLM-2026-004409, billed by a different provider.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-018128	2026-06-14	Evergreen Rehabilitation Center	$272.00	Approved
CLM-2026-004409	2026-06-26	Meadow Regional Medical Center	$4,860.00	Approved
CLM-2026-018551	2026-04-13	Pinecrest Reference Lab	$43.00	Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

The rules engine left this claim for review. The AI adjudicator can read the evidence pack (lines, notes, attachments, coverage, history) and recommend an outcome with citations.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

Approvedscenario: Possible duplicate

Different billing provider; separately payable.

Review queue Member identity