CLM-2026-034645
Heritage Community Hospital, Emergency Medicine. Service 2026-05-04 at emergency room (POS 23). Received 2026-05-13.
Member
Resolved through the identity graph
- Member
- Marilyn Aguilar
- Member ID
- UHC-97377-90
- Date of birth
- 1977-06-02
- Identity
- Verified6 records, confidence 0.97
- Claim record
- CLMCLM-405181
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8608
- Coverage period
- 2024-10-01 to present
- Deductible
- $1,071.51 of $2,500.0043%
- Out-of-pocket maximum
- $1,634.67 of $5,000.0033%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 7 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $223.00 | $122.65 | $122.65 | $0.00 | Paid |
| Totals | $223.00 | $122.65 | $122.65 | $0.00 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. R10.9 Unspecified abdominal pain
- 3. R55 Syncope and collapse
- Patient account
- PA-278481
- 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-002876 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-05-04: SELECT-EPO (EPO), effective 2024-10-01. | |
| Timely filing | Pass | Received 9 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 Hospital2026-05-04 09:44
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-278481.pdf7 pages
Itemised statement totalling $223.00 across 1 line.
- Er reported_report_PA-278481.pdf6 pages
Emergency department record: triage acuity 3, chief complaint chest pain, unspecified.
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-2026-020682 | 2026-08-26 | Pinecrest Family Practice | $439.00 | Approved |
| CLM-2026-016450 | 2026-04-12 | Heritage Primary Care Associates | $259.00 | Approved |
| CLM-2026-001348 | 2026-03-05 | Desert Clinical Laboratories | $156.00 | Approved |
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.