CLM-2026-028546
Heritage Community Hospital, Emergency Medicine. Service 2026-05-21 at emergency room (POS 23). Received 2026-07-02.
Member
Resolved through the identity graph
- Member
- Rebecca Reed
- Member ID
- UHC-81612-39
- Date of birth
- 1958-06-08
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-400373
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-8722
- Coverage period
- 2024-03-01 to 2026-01-01
- Deductible
- $1,080.37 of $2,500.0043%
- Out-of-pocket maximum
- $1,026.45 of $10,000.0010%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 13 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 | $953.00 | $524.15 | — | — | DeniedCO27 |
| 2 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,459.00 | $802.45 | — | — | DeniedCO27 |
| 3 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $169.00 | $92.95 | — | — | DeniedCO27 |
| Totals | $2,581.00 | $1,419.55 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-486268
- 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-036036 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-21 is after coverage terminated on 2026-01-01. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 42 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 Hospital2026-05-21 18:51
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-02 05:47
Attachments
Documents received with the claim
- Itemized billitemized_PA-486268.pdf4 pages
Itemised statement totalling $2581.00 across 3 lines.
- Er reported_report_PA-486268.pdf5 pages
Emergency department record: triage acuity 2, chief complaint chest pain, unspecified.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-05-21 is after coverage terminated on 2026-01-01.
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.