CLM-2026-032995
Heritage Community Hospital, Emergency Medicine. Service 2025-09-22 at emergency room (POS 23). Received 2026-01-23.
Member
Resolved through the identity graph
- Member
- Nicholas Marshall
- Member ID
- UHC-05205-98
- Date of birth
- 1955-12-11
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-431277
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-0468
- Coverage period
- 2024-11-01 to present
- Deductible
- $97.55 of $1,500.007%
- Out-of-pocket maximum
- $806.64 of $3,000.0027%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 7 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 / REF731227
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 | $1,783.00 | $980.65 | — | — | DeniedCO29 |
| 2 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 2 | $3,055.00 | $1,680.25 | — | — | DeniedCO29 |
| Totals | $4,838.00 | $2,660.90 | — | — | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
- Patient account
- PA-903062
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-006926 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-09-22: NAVIGATE-HMO (HMO), effective 2024-11-01. | |
| Timely filing | Fail | CO29 | Received 123 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 (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 Hospital2025-09-22 11:16
Patient seen for pneumonia, unspecified organism.
- SystemSystem: Claims system2026-01-23 03:22
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-903062.pdf6 pages
Itemised statement totalling $4838.00 across 2 lines.
- Er reported_report_PA-903062.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 engineDenied2026-10-22 12:44Timely filing: Received 123 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004547 | 2026-04-13 | Valley Internal Medicine Associates | $238.00 | 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.