CLM-2026-006702
Heritage Community Hospital, Emergency Medicine. Service 2026-09-23 at emergency room (POS 23). Received 2026-10-14.
Member
Resolved through the identity graph
- Member
- Patricia Green
- Member ID
- UHC-31727-18
- Date of birth
- 1963-04-09
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-422639
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2906
- Coverage period
- 2023-08-01 to present
- Deductible
- $1,587.28 of $2,500.0063%
- Out-of-pocket maximum
- $1,221.46 of $5,000.0024%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 2 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 | $3,022.00 | $1,662.10 | $250.00 | $1,412.10 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $212.00 | $116.60 | $0.00 | $116.60 | Paid |
| 3 | 99283 rev 0450 | Emergency department visit, moderate severity | 25 | 1 | 1 | $931.00 | $512.05 | $0.00 | $512.05 | Paid |
| Totals | $4,165.00 | $2,290.75 | $250.00 | $2,040.75 | ||||||
- 1. R55 Syncope and collapseprincipal
- Patient account
- PA-311354
- Frequency code
- 1 (original)
- Accident
- Yes
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-039801 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-09-23: CHOICE-PLUS-PPO (PPO), effective 2023-08-01. | |
| Timely filing | Pass | Received 21 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 Hospital2026-09-23 17:42
Patient seen for syncope and collapse.
Attachments
Documents received with the claim
- Itemized billitemized_PA-311354.pdf3 pages
Itemised statement totalling $4165.00 across 3 lines.
- Er reported_report_PA-311354.pdf2 pages
Emergency department record: triage acuity 3, 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 engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007095 | 2026-06-27 | Canyon Reference Lab | $146.00 | 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.