CLM-2026-007555
Heritage Community Hospital, Emergency Medicine. Service 2026-08-02 at emergency room (POS 23). Received 2026-09-08.
Member
Resolved through the identity graph
- Member
- Ruth Mason
- Member ID
- UHC-21344-69
- Date of birth
- 1990-01-14
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-406742
- Relationship
- Spouse, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-0862
- Coverage period
- 2022-07-01 to present
- Deductible
- $580.39 of $2,500.0023%
- Out-of-pocket maximum
- $1,219.93 of $10,000.0012%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 2102151364
- Network
- In network
- Rendering NPI
- 2102151364
- Location
- Tampa, FL · TIN 69-1549407
- 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 | $1,140.00 | $627.00 | $250.00 | $377.00 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 2 | $243.00 | $133.65 | $0.00 | $133.65 | Paid |
| Totals | $1,383.00 | $760.65 | $250.00 | $510.65 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-627647
- Frequency code
- 1 (original)
- Accident
- No
- 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-006006 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-02: N/A (PPO), effective 2022-07-01. | |
| Timely filing | Pass | Received 37 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 (2102151364). | |
| 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 Hospital2026-08-02 10:36
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-627647.pdf8 pages
Itemised statement totalling $1383.00 across 2 lines.
- Er reported_report_PA-627647.pdf2 pages
Emergency department record: triage acuity 4, chief complaint chest pain, unspecified.
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
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.