CLM-2026-001506
Heritage Medical Group, Internal Medicine. Service 2026-02-02 at office (POS 11). Received 2026-02-18.
Member
Resolved through the identity graph
- Member
- Maria Wells
- Member ID
- UHC-83588-76
- Date of birth
- 2005-07-01
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-421933
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-3375
- Coverage period
- 2023-08-01 to present
- Deductible
- $422.44 of $1,000.0042%
- Out-of-pocket maximum
- $398.73 of $3,000.0013%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 9350331127
- Network
- In network
- Rendering NPI
- 2791198742
- Location
- Denver, CO · TIN 85-4450273
- Authorisation / referral
- none / REF944892
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 | $279.00 | $172.98 | — | — | DeniedCO18 |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 1,2 | $334.00 | $207.08 | — | — | DeniedCO18 |
| Totals | $613.00 | $380.06 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-456963
- 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-012710 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-02: NAVIGATE-HMO (HMO), effective 2023-08-01. | |
| Timely filing | Pass | Received 16 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-001505: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Heritage Medical Group (9350331127). | |
| 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 Medical Group2026-02-02 10:09
Patient seen for chronic kidney disease, stage 3 unspecified.
- SystemSystem: Claims system2026-02-18 00:42
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-001505: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011768 | 2026-08-31 | Lakeside Bone and Joint Center | $33,484.00 | Needs review |
| CLM-2026-022659 | 2026-03-02 | Desert Medical Group | $506.00 | Denied |
| CLM-2026-001505 | 2026-02-02 | Heritage Medical Group | $613.00 | Approved |
| CLM-2026-019498 | 2026-01-02 | Canyon Diagnostic Imaging | $542.00 | Needs review |
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
Exact duplicate of an earlier submission.