CLM-2026-026855
Heritage Community Hospital, Emergency Medicine. Service 2026-07-10 at emergency room (POS 23). Received 2026-07-15.
Member
Resolved through the identity graph
- Member
- Mark Sandoval
- Member ID
- UHC-24042-47
- Date of birth
- 2006-03-22
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-416755
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-0263
- Coverage period
- 2024-10-01 to 2026-03-26
- Deductible
- $2,300.62 of $3,500.0066%
- Out-of-pocket maximum
- $23.01 of $10,500.000%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 20 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 | $2,703.00 | $1,486.65 | — | — | DeniedCO27 |
| Totals | $2,703.00 | $1,486.65 | — | — | ||||||
- 1. S93.401A Sprain of unspecified ligament of right ankle, initial encounterprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-192646
- 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-005454 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-10 is after coverage terminated on 2026-03-26. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 5 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 14:43
Patient seen for sprain of unspecified ligament of right ankle, initial encounter.
- SystemSystem: Claims system2026-07-15 01:55
Attachments
Documents received with the claim
- Itemized billitemized_PA-192646.pdf8 pages
Itemised statement totalling $2703.00 across 1 line.
- Er reported_report_PA-192646.pdf3 pages
Emergency department record: triage acuity 4, chief complaint sprain of unspecified ligament of right ankle, initial encounter.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-07-10 is after coverage terminated on 2026-03-26.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017201 | 2025-12-05 | Northgate Cardiovascular Associates | $6,294.00 | Approved |
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.