CLM-2026-003931
Heritage Medical Group, Internal Medicine. Service 2025-11-19 to 2025-11-21 at inpatient hospital (POS 21). Received 2026-05-15.
Member
Resolved through the identity graph
- Member
- Janice Reid
- Member ID
- UHC-94482-66
- Date of birth
- 1952-10-16
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-409938
- Relationship
- Spouse, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4413
- Coverage period
- 2023-01-01 to present
- Deductible
- $2,093.77 of $2,500.0084%
- Out-of-pocket maximum
- $1,533.94 of $7,500.0020%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 5190573977
- Network
- In network
- Rendering NPI
- 4311631277
- Location
- Austin, TX · TIN 10-1675475
- Authorisation / referral
- none / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $260.00 | $143.00 | — | — | DeniedCO29 |
| Totals | $260.00 | $143.00 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-320851
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2025-11-19 to 2025-11-20
- 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-018821 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-11-19: UNKNOWN (PPO), effective 2023-01-01. | |
| Timely filing | Fail | CO29 | Received 175 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 Medical Group (5190573977). | |
| 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 Group2025-11-21 14:41
Patient seen for type 2 diabetes mellitus with hyperglycemia.
- SystemSystem: Claims system2026-05-15 04:54
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-05-15 09:38
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-320851.pdf5 pages
Itemised statement totalling $260.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 175 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032291 | 2026-09-29 | Meadow Clinical Laboratories | $197.00 | 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.