CLM-2026-004072
Heritage Family Practice, Family Medicine. Service 2026-02-20 at office (POS 11). Received 2026-03-18.
Member
Resolved through the identity graph
- Member
- Nicholas Aguilar
- Member ID
- UHC-37259-61
- Date of birth
- 1977-02-10
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-410974
- Relationship
- Child, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-1450
- Coverage period
- 2023-09-01 to present
- Deductible
- $14.35 of $1,000.001%
- Out-of-pocket maximum
- $1,198.14 of $3,000.0040%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 9531696935
- Network
- In network
- Rendering NPI
- 2739404236
- Location
- Scottsdale, AZ · TIN 58-2905850
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $320.00 | $198.40 | $20.00 | $178.40 | Paid |
| Totals | $320.00 | $198.40 | $20.00 | $178.40 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. M54.50 Low back pain, unspecified
- 3. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-502993
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-020408 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-20: CORE-HMO (HMO), effective 2023-09-01. | |
| Timely filing | Pass | Received 26 days after service (limit 90). | |
| 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 Family Practice (9531696935). | |
| 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 Family Practice2026-02-20 09:16
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.