CLM-2026-033857
Heritage Community Hospital, Emergency Medicine. Service 2025-12-13 at emergency room (POS 23). Received 2026-01-20.
Member
Resolved through the identity graph
- Member
- Albert Payne
- Member ID
- UHC-86332-25
- Date of birth
- 1943-07-04
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-409597
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-6538
- Coverage period
- 2024-10-01 to present
- Deductible
- $544.09 of $3,500.0016%
- Out-of-pocket maximum
- $1,804.24 of $7,000.0026%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 6 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $192.00 | $105.60 | $105.60 | $0.00 | Paid |
| 2 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | 25 | 1 | 1 | $2,988.00 | $1,643.40 | $0.00 | $1,643.40 | Paid |
| Totals | $3,180.00 | $1,749.00 | $105.60 | $1,643.40 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- Patient account
- PA-894330
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-005955 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-13: MEDICARE-ADV-B (MA), effective 2024-10-01. | |
| Timely filing | Pass | Received 38 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 Hospital2025-12-13 15:03
Patient seen for pneumonia, unspecified organism.
Attachments
Documents received with the claim
- Itemized billitemized_PA-894330.pdf8 pages
Itemised statement totalling $3180.00 across 2 lines.
- Er reported_report_PA-894330.pdf6 pages
Emergency department record: triage acuity 2, chief complaint pneumonia, unspecified organism.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025314 | 2026-05-27 | Pinecrest Bone and Joint Center | $30,618.00 | Needs review |
| CLM-2026-025313 | 2026-05-27 | Pinecrest Bone and Joint Center | $30,618.00 | Needs review |
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.