CLM-2026-020099
Heritage Community Hospital, Emergency Medicine. Service 2026-06-22 at emergency room (POS 23). Received 2026-07-21.
Member
Resolved through the identity graph
- Member
- Daniel Holmes
- Member ID
- UHC-72010-71
- Date of birth
- 1953-11-18
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-431617
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-4520
- Coverage period
- 2025-10-01 to present
- Deductible
- $1,144.76 of $1,500.0076%
- Out-of-pocket maximum
- $1,298.80 of $6,000.0022%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 5375971814
- Network
- In network
- Rendering NPI
- 5375971814
- Location
- Atlanta, GA · TIN 80-9992257
- 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 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $1,962.00 | $1,079.10 | $350.00 | $729.10 | Paid |
| 2 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,751.00 | $963.05 | $0.00 | $963.05 | Paid |
| Totals | $3,713.00 | $2,042.15 | $350.00 | $1,692.15 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. R07.9 Chest pain, unspecified
- 3. R10.9 Unspecified abdominal pain
- Patient account
- PA-646334
- 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-034588 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-22: OPTIONS-PPO (PPO), effective 2025-10-01. | |
| Timely filing | Pass | Received 29 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 (5375971814). | |
| 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 Hospital2026-06-22 12:52
Established patient presents with pneumonia, unspecified organism; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-646334.pdf6 pages
Itemised statement totalling $3713.00 across 2 lines.
- Er reported_report_PA-646334.pdf5 pages
Emergency department record: triage acuity 3, 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-2026-005407 | 2026-08-12 | Mesa Family Practice | $528.00 | Approved |
| CLM-2026-013065 | 2026-06-10 | Summit Medical Group | $351.00 | 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.