CLM-2026-033909
Heritage Community Hospital, Emergency Medicine. Service 2026-07-28 at emergency room (POS 23). Received 2026-08-24.
Member
Resolved through the identity graph
- Member
- Mateo Price
- Member ID
- none on golden record
- Date of birth
- 2008-02-20
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-429932
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by name and date of birth
- Plan
- OPTIONS-PPO PPO group GRP-5856
- Coverage period
- 2021-01-01 to present
- Deductible
- $941.45 of $2,500.0038%
- Out-of-pocket maximum
- $720.91 of $5,000.0014%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 10 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 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $1,812.00 | $996.60 | $150.00 | $846.60 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | 25 | 1 | 2 | $140.00 | $77.00 | $0.00 | $77.00 | Paid |
| Totals | $1,952.00 | $1,073.60 | $150.00 | $923.60 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-612834
- 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-042408 (provisional, link confidence 1.00). | |
| Eligibility | Note | Active on 2026-07-28: OPTIONS-PPO (PPO), effective 2021-01-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 27 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 Hospital2026-07-28 14:01
Follow-up for pneumonia, unspecified organism. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-612834.pdf4 pages
Itemised statement totalling $1952.00 across 2 lines.
- Er reported_report_PA-612834.pdf4 pages
Emergency department record: triage acuity 4, 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 engineApproved2026-10-22 12:44Eligibility: Active on 2026-07-28: OPTIONS-PPO (PPO), effective 2021-01-01. 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
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.