CLM-2026-024845
Heritage Community Hospital, Emergency Medicine. Service 2026-07-10 at emergency room (POS 23). Received 2026-07-31.
Member
Resolved through the identity graph
- Member
- Stephen Nguyen
- Member ID
- UHC-57883-51
- Date of birth
- 1998-12-10
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-405437
- Relationship
- Spouse, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-2317
- Coverage period
- 2023-05-01 to present
- Deductible
- $1,155.11 of $1,500.0077%
- Out-of-pocket maximum
- $2,037.74 of $6,000.0034%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $160.00 | $88.00 | $88.00 | $0.00 | Paid |
| 2 | 96374 rev 0260 | IV push, single drug | — | 1 | 2 | $207.00 | $113.85 | $0.00 | $113.85 | Paid |
| Totals | $367.00 | $201.85 | $88.00 | $113.85 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- Patient account
- PA-854862
- 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-040141 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-10: CORE-HMO (HMO), effective 2023-05-01. | |
| Timely filing | Pass | Received 21 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 Hospital2026-07-10 16:16
Follow-up for pneumonia, unspecified organism. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-854862.pdf3 pages
Itemised statement totalling $367.00 across 2 lines.
- Er reported_report_PA-854862.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 engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
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.