CLM-2026-005626
Heritage Community Hospital, Emergency Medicine. Service 2026-08-06 at emergency room (POS 23). Received 2026-09-03.
Member
Resolved through the identity graph
- Member
- Melissa Cruz
- Member ID
- UHC-43441-53
- Date of birth
- 1996-09-15
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-401448
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-8548
- Coverage period
- 2022-11-01 to present
- Deductible
- $568.41 of $1,500.0038%
- Out-of-pocket maximum
- $656.96 of $3,000.0022%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 18 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 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $218.00 | $119.90 | $119.90 | $0.00 | Paid |
| Totals | $218.00 | $119.90 | $119.90 | $0.00 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. J18.9 Pneumonia, unspecified organism
- Patient account
- PA-637291
- 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-017340 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-06: OPTIONS-PPO (PPO), effective 2022-11-01. | |
| Timely filing | Pass | Received 28 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 Hospital2026-08-06 14:57
Patient seen for unspecified abdominal pain.
Attachments
Documents received with the claim
- Itemized billitemized_PA-637291.pdf7 pages
Itemised statement totalling $218.00 across 1 line.
- Er reported_report_PA-637291.pdf6 pages
Emergency department record: triage acuity 3, chief complaint unspecified abdominal pain.
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-2026-011882 | 2026-09-19 | Riverside Primary Care Associates | $140.00 | Approved |
| CLM-2026-028503 | 2026-07-12 | Mesa Medical Group | $3,132.00 | Needs review |
| CLM-2026-022346 | 2026-01-31 | Valley Primary Care Associates | $55.00 | Approved |
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.