Claims workbench/CLM-2026-000515
Professional claim · CMS-1500 · EDI 837P

CLM-2026-000515

Heritage Primary Care Associates, Family Medicine. Service 2026-02-03 at office (POS 11). Received 2026-03-13.

Denied
Billed
$13.00
1 line
Allowed
$8.06
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Jacob Maldonado
Member ID
UHC-78781-64
Date of birth
1996-07-26
Identity
Verified2 records, confidence 0.97
Claim record
CLMCLM-420756
Relationship
Self, San Diego, CA

Coverage and accumulators

Found by member ID

Plan
SELECT-EPO EPO group GRP-3576
Coverage period
2025-05-01 to 2026-01-28
Deductible
$918.33 of $1,500.0061%
Out-of-pocket maximum
$911.14 of $4,500.0020%
Copays
office $40.00, specialist $40.00, emergency $350.00
Physical therapy visits
14 of 20 used

Provider

Billing and rendering

Billing provider
Heritage Primary Care Associates
Family Medicine · taxonomy 207Q00000X
NPI
2218360602
Network
In network
Rendering NPI
3777117318
Location
Atlanta, GA · TIN 79-7884821
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
136415Venipuncture—11$13.00$8.06——DeniedCO27
Totals$13.00$8.06——
Diagnoses (ICD-10-CM)
  • 1. I10 Essential (primary) hypertensionprincipal
Claim header
Patient account
PA-912720
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-018724 (verified, link confidence 0.97).
EligibilityFailCO27Date of service 2026-02-03 is after coverage terminated on 2026-01-28.
Expenses incurred after coverage terminated
Timely filingPassReceived 38 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Heritage Primary Care Associates (2218360602).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Heritage Primary Care Associates2026-02-03 14:16

    Patient seen for essential (primary) hypertension.

  • SystemSystem: Claims system2026-03-13 04:46

  • AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-03-13 16:14

    Reviewed with the member's history on file. Holding for the items listed above.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineDenied2026-10-21 13:43
    Eligibility: Date of service 2026-02-03 is after coverage terminated on 2026-01-28.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

DeniedCO27scenario: Coverage terminated

Service after coverage termination.

Review queueMember identity