CLM-2026-029246
Heritage Community Hospital, Emergency Medicine. Service 2026-02-07 at emergency room (POS 23). Received 2026-03-13.
Member
Resolved through the identity graph
- Member
- John Rivera
- Member ID
- UHC-71931-15
- Date of birth
- 2006-11-10
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-411527
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-2603
- Coverage period
- 2022-10-01 to present
- Deductible
- $230.41 of $500.0046%
- Out-of-pocket maximum
- $194.02 of $1,000.0019%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 13 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 | $2,993.00 | $1,646.15 | $350.00 | $1,296.15 | Paid |
| 2 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 2 | $1,227.00 | $674.85 | $0.00 | $674.85 | Paid |
| Totals | $4,220.00 | $2,321.00 | $350.00 | $1,971.00 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. J18.9 Pneumonia, unspecified organism
- Patient account
- PA-226409
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-019479 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-07: NULL (PPO), effective 2022-10-01. | |
| Timely filing | Pass | Received 34 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 Hospital2026-02-07 18:12
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-226409.pdf5 pages
Itemised statement totalling $4220.00 across 2 lines.
- Er reported_report_PA-226409.pdf2 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 engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
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.