Claims workbench/CLM-2026-021456
Institutional claim · UB-04 · EDI 837I

CLM-2026-021456

Heritage Community Hospital, Emergency Medicine. Service 2026-08-08 at emergency room (POS 23). Received 2026-08-12.

Pended
Billed
$1,479.00
2 lines
Allowed
$813.45
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
N30
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Eugene McCoy
Member ID
none on golden record
Date of birth
1991-06-01
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-426964
Relationship
Self, Glendale, AZ

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Heritage Community Hospital
Emergency 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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
196374
rev 0260
IV push, single drug—11$154.00$84.70——PendedN30
299284
rev 0450
Emergency department visit, high severity—11,2$1,325.00$728.75——PendedN30
Totals$1,479.00$813.45——
Diagnoses (ICD-10-CM)
  • 1. J18.9 Pneumonia, unspecified organismprincipal
  • 2. R07.9 Chest pain, unspecified
Claim header
Patient account
PA-139709
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-041337 (provisional, link confidence 1.00).
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 4 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Heritage Community Hospital (9421157162).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Heritage Community Hospital2026-08-08 10:45

    Patient seen for pneumonia, unspecified organism.

Attachments

Documents received with the claim

  • Itemized billitemized_PA-139709.pdf3 pages

    Itemised statement totalling $1479.00 across 2 lines.

  • Er reported_report_PA-139709.pdf5 pages

    Emergency department record: triage acuity 2, chief complaint pneumonia, unspecified organism.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-22 12:44
    Eligibility: No coverage segment found for the member ID on this claim.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queueMember identity