CLM-2026-018708
Heritage Community Hospital, Emergency Medicine. Service 2026-04-06 at emergency room (POS 23). Received 2026-04-26.
Member
Resolved through the identity graph
- Member
- Jacob Patterson
- Member ID
- UHC-78868-43
- Date of birth
- 1994-09-20
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-427181
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6264
- Coverage period
- 2022-02-01 to present
- Deductible
- $949.44 of $2,500.0038%
- Out-of-pocket maximum
- $75.75 of $5,000.002%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 9 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $198.00 | $108.90 | $108.90 | $0.00 | Paid |
| 2 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 2 | $3,075.00 | $1,691.25 | $0.00 | $1,691.25 | Paid |
| Totals | $3,273.00 | $1,800.15 | $108.90 | $1,691.25 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-318307
- 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-011261 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-06: NULL (PPO), effective 2022-02-01. | |
| Timely filing | Pass | Received 20 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 Hospital2026-04-06 12:40
Patient seen for pneumonia, unspecified organism.
Attachments
Documents received with the claim
- Itemized billitemized_PA-318307.pdf3 pages
Itemised statement totalling $3273.00 across 2 lines.
- Er reported_report_PA-318307.pdf6 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-2026-014367 | 2026-07-02 | Canyon Internal Medicine Associates | $369.00 | Approved |
| CLM-2026-034220 | 2026-02-25 | Evergreen Primary Care Associates | $382.00 | Needs review |
| CLM-2026-034219 | 2026-02-25 | Meadow Family Practice | $382.00 | Approved |
| CLM-2026-015131 | 2026-01-23 | Lakeside Medical Group | $187.00 | 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.