CLM-2026-027962
Heritage Community Hospital, Emergency Medicine. Service 2026-06-12 at emergency room (POS 23). Received 2026-07-18.
Member
Resolved through the identity graph
- Member
- Amanda Washington
- Member ID
- UHC-52121-96
- Date of birth
- 1998-05-28
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-405701
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-1072
- Coverage period
- 2021-09-01 to 2026-04-13
- Deductible
- $252.47 of $1,500.0017%
- Out-of-pocket maximum
- $1,472.80 of $3,000.0049%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 0 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 | $2,058.00 | $1,131.90 | — | — | DeniedCO27 |
| Totals | $2,058.00 | $1,131.90 | — | — | ||||||
- 1. S93.401A Sprain of unspecified ligament of right ankle, initial encounterprincipal
- 2. J18.9 Pneumonia, unspecified organism
- 3. R55 Syncope and collapse
- Patient account
- PA-700822
- 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-014105 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-12 is after coverage terminated on 2026-04-13. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 36 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 Hospital2026-06-12 13:24
Established patient presents with sprain of unspecified ligament of right ankle, initial encounter; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-18 04:05
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-07-18 11:54
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-700822.pdf7 pages
Itemised statement totalling $2058.00 across 1 line.
- Er reported_report_PA-700822.pdf6 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 2026-06-12 is after coverage terminated on 2026-04-13.
Other claims for this member
Same resolved identity
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.