CLM-2026-001655
Heritage Primary Care Associates, Family Medicine. Service 2025-06-29 at office (POS 11). Received 2026-01-18.
Member
Resolved through the identity graph
- Member
- Teresa Spencer
- Member ID
- UHC-23682-43
- Date of birth
- 1995-05-10
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-428442
- Relationship
- Spouse, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group NULL
- Coverage period
- 2023-10-01 to present
- Deductible
- $1,244.08 of $2,500.0050%
- Out-of-pocket maximum
- $2,018.16 of $7,500.0027%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 3703132464
- Network
- In network
- Rendering NPI
- 4244705586
- Location
- Tempe, AZ · TIN 64-9033821
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $198.00 | $122.76 | — | — | DeniedCO29 |
| Totals | $198.00 | $122.76 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-199671
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-005602 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-06-29: UNKNOWN (PPO), effective 2023-10-01. | |
| Timely filing | Fail | CO29 | Received 203 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 (3703132464). | |
| 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 Associates2025-06-29 09:04
Patient seen for hyperlipidemia, unspecified.
- SystemSystem: Claims system2026-01-18 02:15
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-01-18 14:08
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 203 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033137 | 2026-08-29 | Desert Primary Care Associates | $456.00 | Approved |
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
Received after the timely-filing limit.