CLM-2026-026950
Heritage Community Hospital, Emergency Medicine. Service 2026-01-28 at emergency room (POS 23). Received 2026-03-12.
Member
Resolved through the identity graph
- Member
- Helen Ellis
- Member ID
- UHC-73490-52
- Date of birth
- 2008-02-12
- Identity
- Verified6 records, confidence 0.97
- Claim record
- CLMCLM-430293
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-2592
- Coverage period
- 2025-04-01 to present
- Deductible
- $1,196.06 of $3,500.0034%
- Out-of-pocket maximum
- $1,540.92 of $14,000.0011%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 11 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 / REF301951
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 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,297.00 | $713.35 | $250.00 | $463.35 | Paid |
| Totals | $1,297.00 | $713.35 | $250.00 | $463.35 | ||||||
- 1. R55 Syncope and collapseprincipal
- 2. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- 3. J18.9 Pneumonia, unspecified organism
- Patient account
- PA-542931
- 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-016740 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-28: NAVIGATE-HMO (HMO), effective 2025-04-01. | |
| Timely filing | Pass | Received 43 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 Hospital2026-01-28 15:25
Patient seen for syncope and collapse.
Attachments
Documents received with the claim
- Itemized billitemized_PA-542931.pdf5 pages
Itemised statement totalling $1297.00 across 1 line.
- Er reported_report_PA-542931.pdf2 pages
Emergency department record: triage acuity 3, chief complaint syncope and collapse.
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-2026-006269 | 2026-07-13 | Sunrise Heart Institute | $7,790.00 | Approved |
| CLM-2026-020105 | 2026-06-15 | Evergreen Medical Group | $242.00 | Needs review |
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.