CLM-2026-005810
Heritage Community Hospital, Emergency Medicine. Service 2026-03-27 at emergency room (POS 23). Received 2026-05-06.
Member
Resolved through the identity graph
- Member
- David Brooks
- Member ID
- UHC-87270-42
- Date of birth
- 1939-05-06
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-423559
- Relationship
- Spouse, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1199
- Coverage period
- 2023-10-01 to present
- Deductible
- $319.20 of $1,000.0032%
- Out-of-pocket maximum
- $1,964.86 of $4,000.0049%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 4 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 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $2,676.00 | $1,471.80 | $150.00 | $1,321.80 | Paid |
| Totals | $2,676.00 | $1,471.80 | $150.00 | $1,321.80 | ||||||
- 1. R55 Syncope and collapseprincipal
- 2. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- 3. J18.9 Pneumonia, unspecified organism
- Patient account
- PA-336587
- 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-029412 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-27: CHOICE-PLUS-PPO (PPO), effective 2023-10-01. | |
| Timely filing | Pass | Received 40 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 Hospital2026-03-27 11:24
Patient seen for syncope and collapse.
Attachments
Documents received with the claim
- Itemized billitemized_PA-336587.pdf6 pages
Itemised statement totalling $2676.00 across 1 line.
- Er reported_report_PA-336587.pdf3 pages
Emergency department record: triage acuity 2, chief complaint syncope and collapse.
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-2026-024972 | 2026-08-30 | Sunrise Digestive Health Center | $3,580.00 | Approved |
| CLM-2026-005811 | 2026-03-27 | Heritage Community Hospital | $2,676.00 | Needs review |
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.