Professional claim · CMS-1500 · EDI 837P
CLM-2026-000568
Heritage Medical Group, Family Medicine. Service 2026-05-11 at office (POS 11). Received 2026-06-04.
Billed
$760.00
3 lines
Allowed
$342.00
if approved
Plan pays
—
Pended
Member owes
—
copay / deductible / 10% coinsurance
Rules engine
Pend
IDQ
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Paul Valdez
- Member ID
- none on golden record
- Date of birth
- 1957-11-17
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-431170
- Relationship
- Spouse
Coverage and accumulators
Found by name and date of birth
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7612
- Coverage period
- 2025-06-01 to present
- Deductible
- $640.30 of $1,500.0043%
- Out-of-pocket maximum
- $650.49 of $3,000.0022%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 1536032422
- Network
- Out of network
- Rendering NPI
- 4069055182
- Location
- Denver, CO · TIN 49-9592909
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $253.00 | $113.85 | — | — | PendedIDQ |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1,2 | $310.00 | $139.50 | — | — | PendedIDQ |
| 3 | 99203 | Office visit, new patient, low complexity | 25 | 1 | 2 | $197.00 | $88.65 | — | — | PendedIDQ |
| Totals | $760.00 | $342.00 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. E78.5 Hyperlipidemia, unspecified
Claim header
- Patient account
- PA-498269
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-001657; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-05-11: NULL (PPO), effective 2025-06-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 24 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Pended.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Heritage Medical Group2026-05-11 14:51
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-001657; payment withheld until the identity is confirmed. Eligibility: Active on 2026-05-11: NULL (PPO), effective 2025-06-01. Coverage found by name and date of birth because the claim carried no usable member ID. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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
Record the final decision; pricing and remittance reasons follow from it
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
Approvedscenario: Clean
Clean claim, priced at contract rate.