CLM-2026-010013
Heritage Community Hospital, Emergency Medicine. Service 2026-05-07 at emergency room (POS 23). Received 2026-06-07.
Member
Resolved through the identity graph
- Member
- Cheryl Martinez
- Member ID
- UHC-03389-40
- Date of birth
- 1982-05-06
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-428078
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-7545
- Coverage period
- 2023-06-01 to present
- Deductible
- $702.62 of $1,500.0047%
- Out-of-pocket maximum
- $290.48 of $3,000.0010%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 14 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 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $634.00 | $348.70 | $250.00 | $98.70 | Paid |
| 2 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $2,362.00 | $1,299.10 | $0.00 | $1,299.10 | Paid |
| 3 | 96374 rev 0260 | IV push, single drug | — | 1 | 2 | $187.00 | $102.85 | $0.00 | $102.85 | Paid |
| Totals | $3,183.00 | $1,750.65 | $250.00 | $1,500.65 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-882737
- 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-024025 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-05-07: OPTIONS-PPO (PPO), effective 2023-06-01. | |
| Timely filing | Pass | Received 31 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 Hospital2026-05-07 14:14
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-882737.pdf8 pages
Itemised statement totalling $3183.00 across 3 lines.
- Er reported_report_PA-882737.pdf6 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029667 | 2026-02-25 | Riverside Imaging Center | $3,191.00 | 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.