CLM-2026-023097
Heritage Community Hospital, Emergency Medicine. Service 2025-12-21 at emergency room (POS 23). Received 2026-01-26.
Member
Resolved through the identity graph
- Member
- Tyler Meyer
- Member ID
- UHC-68314-07
- Date of birth
- 1949-04-04
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-420548
- Relationship
- Child, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-7215
- Coverage period
- 2025-08-01 to present
- Deductible
- $331.60 of $1,500.0022%
- Out-of-pocket maximum
- $904.49 of $3,000.0030%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 2102151364
- Network
- In network
- Rendering NPI
- 2102151364
- Location
- Tampa, FL · TIN 69-1549407
- 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 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $159.00 | $87.45 | $87.45 | $0.00 | Paid |
| Totals | $159.00 | $87.45 | $87.45 | $0.00 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- 3. R07.9 Chest pain, unspecified
- Patient account
- PA-123819
- 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-007743 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-21: OPTIONS-PPO (PPO), effective 2025-08-01. | |
| Timely filing | Pass | Received 36 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 (2102151364). | |
| 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 Hospital2025-12-21 15:44
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-123819.pdf2 pages
Itemised statement totalling $159.00 across 1 line.
- Er reported_report_PA-123819.pdf2 pages
Emergency department record: triage acuity 4, chief complaint unspecified abdominal pain.
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-034039 | 2026-10-01 | Pinecrest Bone and Joint Center | $3,117.00 | Needs review |
| CLM-2026-016609 | 2025-12-30 | Evergreen Digestive Health Center | $4,111.00 | 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.