CLM-2026-004527
Heritage Internal Medicine Associates, Internal Medicine. Service 2025-12-13 at office (POS 11). Received 2026-01-27.
Member
Resolved through the identity graph
- Member
- Debra Hoffman
- Member ID
- UHC-99555-59
- Date of birth
- 1989-03-03
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-402254
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-9169
- Coverage period
- 2025-11-01 to present
- Deductible
- $395.87 of $1,000.0040%
- Out-of-pocket maximum
- $140.70 of $2,000.007%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6689259359
- Network
- In network
- Rendering NPI
- 2510541610
- Location
- Miami, FL · TIN 57-4041631
- 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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $85.00 | $52.70 | $20.00 | $32.70 | Paid |
| Totals | $85.00 | $52.70 | $20.00 | $32.70 | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- Patient account
- PA-193659
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-007954 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-13: CHOICE-PLUS-PPO (PPO), effective 2025-11-01. | |
| Timely filing | Pass | Received 45 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 Internal Medicine Associates (6689259359). | |
| 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 Internal Medicine Associates2025-12-13 15:58
Patient seen for type 2 diabetes mellitus with hyperglycemia.
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 engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010834 | 2026-07-28 | Sunrise Skin Care Associates | $765.00 | Approved |
| CLM-2026-013153 | 2026-02-18 | Lakeside Medical Group | $251.00 | Approved |
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.