CLM-2026-032553
Heritage Community Hospital, Emergency Medicine. Service 2026-06-06 at emergency room (POS 23). Received 2026-09-13.
Member
Resolved through the identity graph
- Member
- Kelly Herrera
- Member ID
- UHC-57765-55
- Date of birth
- 1953-01-10
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-425409
- Relationship
- Child, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-9327
- Coverage period
- 2024-04-01 to present
- Deductible
- $2,649.55 of $3,500.0076%
- Out-of-pocket maximum
- $223.00 of $7,000.003%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 6 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $136.00 | $74.80 | — | — | DeniedCO29 |
| Totals | $136.00 | $74.80 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-207984
- 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-025064 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-06: OPTIONS-PPO (PPO), effective 2024-04-01. | |
| Timely filing | Fail | CO29 | Received 99 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Hospital2026-06-06 11:11
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-13 05:15
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
- Itemized billitemized_PA-207984.pdf9 pages
Itemised statement totalling $136.00 across 1 line.
- Er reported_report_PA-207984.pdf5 pages
Emergency department record: triage acuity 2, chief complaint unspecified abdominal pain.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 99 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012531 | 2026-03-25 | Harbor Medical Group | $493.00 | Approved |
| CLM-2026-020472 | 2026-03-11 | Sunrise Medical Group | $14.00 | Approved |
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
Received after the timely-filing limit.