CLM-2026-026380
Heritage Community Hospital, Emergency Medicine. Service 2026-02-10 at emergency room (POS 23). Received 2026-02-16.
Member
Resolved through the identity graph
- Member
- Joe Ford
- Member ID
- UHC-43516-61
- Date of birth
- 1978-09-19
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-412576
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-8913
- Coverage period
- 2022-05-01 to present
- Deductible
- $2,595.52 of $3,500.0074%
- Out-of-pocket maximum
- $2,968.76 of $10,500.0028%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Community HospitalEmergency 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
| 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 | $2,812.00 | $1,546.60 | $350.00 | $1,196.60 | Paid |
| Totals | $2,812.00 | $1,546.60 | $350.00 | $1,196.60 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- Patient account
- PA-346506
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-013387 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-10: MEDICARE-ADV-A (MA), effective 2022-05-01. | |
| Timely filing | Pass | Received 6 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 (9421157162). | |
| 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 Hospital2026-02-10 14:12
Follow-up for pneumonia, unspecified organism. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-346506.pdf6 pages
Itemised statement totalling $2812.00 across 1 line.
- Er reported_report_PA-346506.pdf6 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 engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012676 | 2026-03-22 | Mesa Primary Care Associates | $240.00 | Approved |
| CLM-2026-013382 | 2026-02-03 | Northgate Medical Group | $334.00 | 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.