CLM-2026-012579
Heritage Community Hospital, Emergency Medicine. Service 2026-06-19 at emergency room (POS 23). Received 2026-08-03.
Member
Resolved through the identity graph
- Member
- Sean Silva
- Member ID
- UHC-15160-88
- Date of birth
- 1959-05-03
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-410565
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-0782
- Coverage period
- 2025-07-01 to 2026-01-16
- Deductible
- $436.44 of $1,000.0044%
- Out-of-pocket maximum
- $1,360.86 of $3,000.0045%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 0 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 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $148.00 | $81.40 | — | — | DeniedCO27 |
| Totals | $148.00 | $81.40 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. J18.9 Pneumonia, unspecified organism
- Patient account
- PA-738237
- 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-017193 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-19 is after coverage terminated on 2026-01-16. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 45 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 Hospital2026-06-19 14:25
Patient seen for unspecified abdominal pain.
- SystemSystem: Claims system2026-08-03 02:13
Attachments
Documents received with the claim
- Itemized billitemized_PA-738237.pdf8 pages
Itemised statement totalling $148.00 across 1 line.
- Er reported_report_PA-738237.pdf4 pages
Emergency department record: triage acuity 2, chief complaint unspecified abdominal pain.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-06-19 is after coverage terminated on 2026-01-16.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022864 | 2026-06-24 | Evergreen Cardiovascular Associates | $365.00 | 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.