CLM-2026-003797
Heritage Primary Care Associates, Family Medicine. Service 2026-04-06 at office (POS 11). Received 2026-05-07.
Member
Resolved through the identity graph
- Member
- Elijah Clark
- Member ID
- UHC-88160-82
- Date of birth
- 1945-08-06
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-424528
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-4244
- Coverage period
- 2022-09-01 to present
- Deductible
- $933.05 of $1,500.0062%
- Out-of-pocket maximum
- $290.41 of $4,500.006%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 2229159530
- Network
- In network
- Rendering NPI
- 9429446708
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $264.00 | $163.68 | — | — | DeniedCO18 |
| 2 | 99203 | Office visit, new patient, low complexity | 25 | 1 | 1,2 | $228.00 | $141.36 | — | — | DeniedCO18 |
| 3 | 36415 | Venipuncture | — | 1 | 2 | $15.00 | $9.30 | — | — | DeniedCO18 |
| Totals | $507.00 | $314.34 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-743901
- 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-028760 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-06: CORE-HMO (HMO), effective 2022-09-01. | |
| Timely filing | Pass | Received 31 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-003796: 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 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 Associates2026-04-06 10:02
Patient seen for acute upper respiratory infection, unspecified.
- SystemSystem: Claims system2026-05-07 03:04
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 engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-003796: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-026311 | 2026-07-18 | Pinecrest Medical Group | $98.00 | Approved |
| CLM-2026-003796 | 2026-04-06 | Heritage Primary Care Associates | $507.00 | 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
Exact duplicate of an earlier submission.