CLM-2026-000327
Heritage Primary Care Associates, Family Medicine. Service 2026-09-07 at office (POS 11). Received 2026-09-17.
Member
Resolved through the identity graph
- Member
- Frances Harvey
- Member ID
- UHC-53627-10
- Date of birth
- 1985-03-28
- Identity
- Verified5 records, confidence 0.98
- Claim record
- CLMCLM-412345
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1326
- Coverage period
- 2023-05-01 to present
- Deductible
- $208.84 of $3,500.006%
- Out-of-pocket maximum
- $6,960.48 of $14,000.0050%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 5397655734
- Network
- In network
- Rendering NPI
- 3401441597
- Location
- Tampa, FL · TIN 61-8345625
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $212.00 | $131.44 | $30.00 | $101.44 | Paid |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $232.00 | $143.84 | $0.00 | $143.84 | Paid |
| 3 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $330.00 | $204.60 | $0.00 | $204.60 | Paid |
| Totals | $774.00 | $479.88 | $30.00 | $449.88 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- Patient account
- PA-471615
- 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-014197 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2026-09-07: - (PPO), effective 2023-05-01. | |
| Timely filing | Pass | Received 10 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 Primary Care Associates (5397655734). | |
| 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 Primary Care Associates2026-09-07 14:30
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
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-2026-016209 | 2026-03-04 | Pinecrest Clinical Laboratories | $146.00 | 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.