CLM-2026-001089
Heritage Primary Care Associates, Family Medicine. Service 2026-09-07 at office (POS 11). Received 2026-10-05.
Member
Resolved through the identity graph
- Member
- Dorothy Walker
- Member ID
- UHC-09439-74
- Date of birth
- 1980-01-28
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-413228
- Relationship
- Child, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-1743
- Coverage period
- 2025-03-01 to 2026-07-25
- Deductible
- $102.15 of $1,500.007%
- Out-of-pocket maximum
- $622.12 of $3,000.0021%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 2229159530
- Network
- In network
- Rendering NPI
- 3308991868
- Location
- Houston, TX · TIN 14-5202877
- 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 | 90471 | Immunization administration | — | 1 | 1 | $42.00 | $26.04 | — | — | DeniedCO27 |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $287.00 | $177.94 | — | — | DeniedCO27 |
| Totals | $329.00 | $203.98 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- Patient account
- PA-412871
- 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
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-029573 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-07 is after coverage terminated on 2026-07-25. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 28 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 (2229159530). | |
| 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 12:34
Patient seen for hyperlipidemia, unspecified.
- SystemSystem: Claims system2026-10-05 04:06
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-10-05 13:47
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-09-07 is after coverage terminated on 2026-07-25.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.