CLM-2026-010139
Heritage Community Hospital, Emergency Medicine. Service 2026-01-28 at emergency room (POS 23). Received 2026-02-19.
Member
Resolved through the identity graph
- Member
- Gabriel Bradley
- Member ID
- UHC-00034-62
- Date of birth
- 1946-03-05
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-422248
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-9062
- Coverage period
- 2022-01-01 to 2026-01-21
- Deductible
- $189.62 of $2,500.008%
- Out-of-pocket maximum
- $187.36 of $7,500.002%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- 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 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $913.00 | $502.15 | — | — | DeniedCO27 |
| 2 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1,2 | $1,633.00 | $898.15 | — | — | DeniedCO27 |
| Totals | $2,546.00 | $1,400.30 | — | — | ||||||
- 1. R55 Syncope and collapseprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-160095
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-003537 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-01-28 is after coverage terminated on 2026-01-21. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 22 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 Hospital2026-01-28 18:26
Follow-up for syncope and collapse. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-02-19 04:50
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-02-19 10:09
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-160095.pdf3 pages
Itemised statement totalling $2546.00 across 2 lines.
- Er reported_report_PA-160095.pdf5 pages
Emergency department record: triage acuity 3, chief complaint syncope and collapse.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-01-28 is after coverage terminated on 2026-01-21.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031498 | 2026-06-06 | Sunrise Orthopedic Specialists | $182.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.