CLM-2026-001773
Heritage Primary Care Associates, Family Medicine. Service 2025-09-10 at office (POS 11). Received 2026-03-17.
Member
Resolved through the identity graph
- Member
- William Contreras
- Member ID
- UHC-63728-04
- Date of birth
- 2002-04-08
- Identity
- Verified6 records, confidence 0.97
- Claim record
- CLMCLM-410142
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8277
- Coverage period
- 2023-11-01 to present
- Deductible
- $817.67 of $1,000.0082%
- Out-of-pocket maximum
- $253.65 of $2,000.0013%
- Copays
- office $20.00, specialist $40.00, 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
- 5298644548
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $194.00 | $120.28 | — | — | DeniedCO29 |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $235.00 | $145.70 | — | — | DeniedCO29 |
| 3 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $321.00 | $199.02 | — | — | DeniedCO29 |
| Totals | $750.00 | $465.00 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- Patient account
- PA-149390
- 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-012337 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-09-10: CHOICE-PLUS-PPO (PPO), effective 2023-11-01. | |
| Timely filing | Fail | CO29 | Received 188 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 (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 Associates2025-09-10 12:15
Patient seen for acute upper respiratory infection, unspecified.
- SystemSystem: Claims system2026-03-17 01:52
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)2026-03-17 16:49
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 13:43Timely filing: Received 188 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023019 | 2026-10-11 | Lakeside Clinical Laboratories | $60.00 | Approved |
| CLM-2026-013525 | 2026-03-17 | Desert Rehabilitation Center | $158.00 | 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.