CLM-2026-026048
Heritage Community Hospital, Emergency Medicine. Service 2026-05-15 at emergency room (POS 23). Received 2026-05-30.
Member
Resolved through the identity graph
- Member
- Henry Hunter
- Member ID
- UHC-56451-44
- Date of birth
- 1944-09-06
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-403393
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-2749
- Coverage period
- 2024-06-01 to present
- Deductible
- $709.38 of $2,500.0028%
- Out-of-pocket maximum
- $1,622.32 of $5,000.0032%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 14 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 | $1,716.00 | $943.80 | $150.00 | $793.80 | Paid |
| Totals | $1,716.00 | $943.80 | $150.00 | $793.80 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- Patient account
- PA-122195
- 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-001798 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-05-15: - (PPO), effective 2024-06-01. | |
| Timely filing | Pass | Received 15 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 Hospital2026-05-15 09:30
Established patient presents with pneumonia, unspecified organism; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-122195.pdf4 pages
Itemised statement totalling $1716.00 across 1 line.
- Er reported_report_PA-122195.pdf5 pages
Emergency department record: triage acuity 2, 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012967 | 2025-10-25 | Riverside Imaging Center | $1,426.00 | Denied |
| CLM-2026-023782 | 2025-11-24 | Summit Clinical Laboratories | $140.00 | 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.