CLM-2026-008463
Heritage Community Hospital, Emergency Medicine. Service 2026-02-26 at emergency room (POS 23). Received 2026-04-09.
Member
Resolved through the identity graph
- Member
- John Gardner
- Member ID
- UHC-23813-69
- Date of birth
- 1994-01-21
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-401737
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-0927
- Coverage period
- 2024-11-01 to present
- Deductible
- $238.22 of $1,000.0024%
- Out-of-pocket maximum
- $699.62 of $3,000.0023%
- Copays
- office $30.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 3 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 / REF252500
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 | $1,634.00 | $898.70 | $350.00 | $548.70 | Paid |
| Totals | $1,634.00 | $898.70 | $350.00 | $548.70 | ||||||
- 1. R55 Syncope and collapseprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-640325
- Frequency code
- 1 (original)
- Accident
- Yes
- 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-022166 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-26: NAVIGATE-HMO (HMO), effective 2024-11-01. | |
| Timely filing | Pass | Received 42 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 Hospital2026-02-26 10:34
Established patient presents with syncope and collapse; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-640325.pdf8 pages
Itemised statement totalling $1634.00 across 1 line.
- Er reported_report_PA-640325.pdf3 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 engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-015117 | 2026-02-14 | Unity Primary Care Associates | $407.00 | Denied |
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.