CLM-2026-015097
Heritage Community Hospital, Emergency Medicine. Service 2026-07-02 at emergency room (POS 23). Received 2026-07-13.
Member
Resolved through the identity graph
- Member
- David Griffin
- Member ID
- UHC-59486-30
- Date of birth
- 1958-07-13
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-427718
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8582
- Coverage period
- 2024-11-01 to present
- Deductible
- $874.81 of $1,000.0087%
- Out-of-pocket maximum
- $818.72 of $4,000.0020%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 0 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 | $216.00 | $118.80 | $118.80 | $0.00 | Paid |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 2 | $740.00 | $407.00 | $0.00 | $407.00 | Paid |
| Totals | $956.00 | $525.80 | $118.80 | $407.00 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-200753
- Frequency code
- 1 (original)
- Accident
- No
- 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-026913 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-07-02: - (PPO), effective 2024-11-01. | |
| Timely filing | Pass | Received 11 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 Hospital2026-07-02 17:29
Follow-up for pneumonia, unspecified organism. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-200753.pdf2 pages
Itemised statement totalling $956.00 across 2 lines.
- Er reported_report_PA-200753.pdf5 pages
Emergency department record: triage acuity 4, chief complaint pneumonia, unspecified organism.
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-2026-012314 | 2026-08-10 | Mesa Internal Medicine Associates | $114.00 | Approved |
| CLM-2026-007545 | 2026-03-28 | Mesa Diabetes Center | $289.00 | Denied |
| CLM-2026-019710 | 2026-03-08 | Canyon Medical Group | $193.00 | 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.