CLM-2026-032101
Heritage Community Hospital, Emergency Medicine. Service 2026-05-22 at emergency room (POS 23). Received 2026-05-27.
Member
Resolved through the identity graph
- Member
- Charlotte Warren
- Member ID
- none on golden record
- Date of birth
- 1953-12-28
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-410452
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- MEDICARE-ADV-B MA group GRP-0548
- Coverage period
- 2021-11-01 to present
- Deductible
- $203.87 of $1,500.0014%
- Out-of-pocket maximum
- $525.16 of $3,000.0018%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 2102151364
- Network
- In network
- Rendering NPI
- 2102151364
- Location
- Tampa, FL · TIN 69-1549407
- 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 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,659.00 | $912.45 | — | — | PendedIDQ |
| Totals | $1,659.00 | $912.45 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- Patient account
- PA-433726
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-003340; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-05-22: MEDICARE-ADV-B (MA), effective 2021-11-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 5 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 (2102151364). | |
| 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 Hospital2026-05-22 12:33
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-433726.pdf6 pages
Itemised statement totalling $1659.00 across 1 line.
- Er reported_report_PA-433726.pdf6 pages
Emergency department record: triage acuity 4, chief complaint unspecified abdominal pain.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-003340; payment withheld until the identity is confirmed. Eligibility: Active on 2026-05-22: MEDICARE-ADV-B (MA), effective 2021-11-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.