Claims workbench/CLM-2026-029398
Institutional claim · UB-04 · Provider portal

CLM-2026-029398

Heritage Community Hospital, Emergency Medicine. Service 2026-09-06 at emergency room (POS 23). Received 2026-10-13.

Pended
Billed
$1,129.00
2 lines
Allowed
$620.95
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
N30
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
William Carpenter
Member ID
none on golden record
Date of birth
1954-02-11
Identity
Verified2 records, confidence 0.93
Claim record
CLMCLM-416358
Relationship
Self, Denver, CO

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Heritage Community Hospital
Emergency 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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
171046
rev 0320
Chest X-ray, two views—11$143.00$78.65——PendedN30
299283
rev 0450
Emergency department visit, moderate severity—12$986.00$542.30——PendedN30
Totals$1,129.00$620.95——
Diagnoses (ICD-10-CM)
  • 1. S93.401A Sprain of unspecified ligament of right ankle, initial encounterprincipal
Claim header
Patient account
PA-764674
Frequency code
1 (original)
Accident
Yes
DRG
—
Admit / discharge
—
Landed
2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-002900 (verified, link confidence 0.93).
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 37 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Heritage Community Hospital (5375971814).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Heritage Community Hospital2026-09-06 09:32

    Patient seen for sprain of unspecified ligament of right ankle, initial encounter.

Attachments

Documents received with the claim

  • Itemized billitemized_PA-764674.pdf3 pages

    Itemised statement totalling $1129.00 across 2 lines.

  • Er reported_report_PA-764674.pdf6 pages

    Emergency department record: triage acuity 2, chief complaint sprain of unspecified ligament of right ankle, initial encounter.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-21 13:43
    Eligibility: No coverage segment found for the member ID on this claim.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queueMember identity