CLM-2026-028562
Heritage Community Hospital, Emergency Medicine. Service 2026-09-29 at emergency room (POS 23). Received 2026-10-11.
Member
Resolved through the identity graph
- Member
- Douglas Kim
- Member ID
- UHC-49616-13
- Date of birth
- 1940-07-09
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-422932
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-9908
- Coverage period
- 2025-05-01 to 2026-05-22
- Deductible
- $452.10 of $2,500.0018%
- Out-of-pocket maximum
- $966.99 of $7,500.0013%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 2 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 / REF757741
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 | $1,664.00 | $915.20 | — | — | DeniedCO27 |
| Totals | $1,664.00 | $915.20 | — | — | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- Patient account
- PA-599296
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-006054 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-29 is after coverage terminated on 2026-05-22. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 12 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 Hospital2026-09-29 12:54
Established patient presents with pneumonia, unspecified organism; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-10-11 01:45
Attachments
Documents received with the claim
- Itemized billitemized_PA-599296.pdf7 pages
Itemised statement totalling $1664.00 across 1 line.
- Er reported_report_PA-599296.pdf2 pages
Emergency department record: triage acuity 3, chief complaint pneumonia, unspecified organism.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-09-29 is after coverage terminated on 2026-05-22.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033361 | 2026-07-23 | Mesa Clinical Laboratories | $147.00 | Denied |
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.