CLM-2026-008992
Heritage Community Hospital, Emergency Medicine. Service 2026-08-09 at emergency room (POS 23). Received 2026-08-23.
Member
Resolved through the identity graph
- Member
- Karen Simpson
- Member ID
- UHC-89737-33
- Date of birth
- 1987-05-19
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-402476
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-1508
- Coverage period
- 2021-02-01 to present
- Deductible
- $1,362.43 of $2,500.0054%
- Out-of-pocket maximum
- $1,029.67 of $7,500.0014%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 9421157162
- Network
- In network
- Rendering NPI
- 9421157162
- Location
- Scottsdale, AZ · TIN 26-8049060
- 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 | $151.00 | $83.05 | $83.05 | $0.00 | Paid |
| 2 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 2 | $1,785.00 | $981.75 | $0.00 | $981.75 | Paid |
| 3 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $150.00 | $82.50 | $0.00 | $82.50 | Paid |
| Totals | $2,086.00 | $1,147.30 | $83.05 | $1,064.25 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-811722
- 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-011041 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-09: MEDICARE-ADV-A (MA), effective 2021-02-01. | |
| Timely filing | Pass | Received 14 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 (9421157162). | |
| 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 Hospital2026-08-09 09:37
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-811722.pdf5 pages
Itemised statement totalling $2086.00 across 3 lines.
- Er reported_report_PA-811722.pdf2 pages
Emergency department record: triage acuity 2, 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 engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022296 | 2026-01-28 | Heritage Rehabilitation Center | $448.00 | Needs review |
| CLM-2026-022295 | 2026-01-28 | Heritage Rehabilitation Center | $448.00 | 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.