CLM-2026-018636
Heritage Community Hospital, Emergency Medicine. Service 2026-06-20 at emergency room (POS 23). Received 2026-08-04.
Member
Resolved through the identity graph
- Member
- Ronald Pierce
- Member ID
- UHC-99616-62
- Date of birth
- 1938-09-25
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-418780
- Relationship
- Spouse, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-7843
- Coverage period
- 2021-03-01 to present
- Deductible
- $412.79 of $500.0083%
- Out-of-pocket maximum
- $830.28 of $2,000.0042%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 7 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 | $613.00 | $337.15 | $250.00 | $87.15 | Paid |
| 2 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $250.00 | $137.50 | $0.00 | $137.50 | Paid |
| Totals | $863.00 | $474.65 | $250.00 | $224.65 | ||||||
- 1. R55 Syncope and collapseprincipal
- Patient account
- PA-860625
- 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-040626 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-20: OPTIONS-PPO (PPO), effective 2021-03-01. | |
| 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 (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 Hospital2026-06-20 18:51
Follow-up for syncope and collapse. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-860625.pdf3 pages
Itemised statement totalling $863.00 across 2 lines.
- Er reported_report_PA-860625.pdf3 pages
Emergency department record: triage acuity 4, chief complaint syncope and collapse.
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
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.