CLM-2026-022402
Heritage Community Hospital, Emergency Medicine. Service 2026-04-13 at emergency room (POS 23). Received 2026-05-26.
Member
Resolved through the identity graph
- Member
- Lisa Burton
- Member ID
- UHC-23382-54
- Date of birth
- 1945-11-17
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-428636
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-7675
- Coverage period
- 2023-02-01 to 2026-04-03
- Deductible
- $135.33 of $500.0027%
- Out-of-pocket maximum
- $483.61 of $1,000.0048%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 1 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 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $929.00 | $510.95 | — | — | DeniedCO27 |
| 2 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1,2 | $2,177.00 | $1,197.35 | — | — | DeniedCO27 |
| 3 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 2 | $1,580.00 | $869.00 | — | — | DeniedCO27 |
| Totals | $4,686.00 | $2,577.30 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- Patient account
- PA-665823
- 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
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-032317 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-13 is after coverage terminated on 2026-04-03. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 43 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 Hospital2026-04-13 13:31
Patient seen for unspecified abdominal pain.
- SystemSystem: Claims system2026-05-26 02:25
Attachments
Documents received with the claim
- Itemized billitemized_PA-665823.pdf2 pages
Itemised statement totalling $4686.00 across 3 lines.
- Er reported_report_PA-665823.pdf2 pages
Emergency department record: triage acuity 2, chief complaint unspecified abdominal pain.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-04-13 is after coverage terminated on 2026-04-03.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.