CLM-2026-027380
Heritage Community Hospital, Emergency Medicine. Service 2026-01-29 at emergency room (POS 23). Received 2026-03-10.
Member
Resolved through the identity graph
- Member
- Rachel Lopez
- Member ID
- UHC-43524-49
- Date of birth
- 1967-11-16
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-422496
- Relationship
- Spouse, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-0585
- Coverage period
- 2022-01-01 to present
- Deductible
- $305.83 of $3,500.009%
- Out-of-pocket maximum
- $1,440.32 of $7,000.0021%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 6 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 / REF672066
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 | $2,206.00 | $1,213.30 | $350.00 | $863.30 | Paid |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | 25 | 1 | 1,2 | $877.00 | $482.35 | $0.00 | $482.35 | Paid |
| Totals | $3,083.00 | $1,695.65 | $350.00 | $1,345.65 | ||||||
- 1. S93.401A Sprain of unspecified ligament of right ankle, initial encounterprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-761694
- 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-005146 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-29: NAVIGATE-HMO (HMO), effective 2022-01-01. | |
| Timely filing | Pass | Received 40 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 Hospital2026-01-29 11:13
Patient seen for sprain of unspecified ligament of right ankle, initial encounter.
Attachments
Documents received with the claim
- Itemized billitemized_PA-761694.pdf2 pages
Itemised statement totalling $3083.00 across 2 lines.
- Er reported_report_PA-761694.pdf5 pages
Emergency department record: triage acuity 4, chief complaint sprain of unspecified ligament of right ankle, initial encounter.
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-2026-025650 | 2026-10-02 | Cornerstone Orthopedic Specialists | $35,527.00 | Denied |
| CLM-2026-021336 | 2025-12-31 | Lakeside Reference Lab | $67.00 | 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.