CLM-2026-027889
Heritage Community Hospital, Emergency Medicine. Service 2026-05-26 at emergency room (POS 23). Received 2026-06-28.
Member
Resolved through the identity graph
- Member
- Albert Castro
- Member ID
- UHC-91693-71
- Date of birth
- 1982-05-10
- Identity
- Verified4 records, confidence 0.98
- Claim record
- CLMCLM-401458
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-6332
- Coverage period
- 2025-02-01 to present
- Deductible
- $823.35 of $1,500.0055%
- Out-of-pocket maximum
- $1,336.58 of $6,000.0022%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 21 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 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $1,083.00 | $595.65 | $150.00 | $445.65 | Paid |
| 2 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $241.00 | $132.55 | $0.00 | $132.55 | Paid |
| Totals | $1,324.00 | $728.20 | $150.00 | $578.20 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. J18.9 Pneumonia, unspecified organism
- Patient account
- PA-544964
- 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-004012 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2026-05-26: MEDICARE-ADV-A (MA), effective 2025-02-01. | |
| Timely filing | Pass | Received 33 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 Hospital2026-05-26 09:55
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-544964.pdf4 pages
Itemised statement totalling $1324.00 across 2 lines.
- Er reported_report_PA-544964.pdf4 pages
Emergency department record: triage acuity 3, chief complaint unspecified abdominal pain.
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-2026-004352 | 2026-09-05 | Canyon Heart Institute | $7,867.00 | Denied |
| CLM-2026-027890 | 2026-05-26 | Mesa Regional Medical Center | $1,324.00 | 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.