CLM-2026-006564
Heritage Internal Medicine Associates, Internal Medicine. Service 2026-02-25 at office (POS 11). Received 2026-04-08.
Member
Resolved through the identity graph
- Member
- Kathryn Ortega
- Member ID
- UHC-71038-15
- Date of birth
- 1944-08-18
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-414000
- Relationship
- Spouse, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-4846
- Coverage period
- 2024-11-01 to present
- Deductible
- $679.46 of $3,500.0019%
- Out-of-pocket maximum
- $1,188.00 of $10,500.0011%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6689259359
- Network
- In network
- Rendering NPI
- 4298448380
- 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 | $114.00 | $70.68 | $40.00 | $30.68 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $206.00 | $127.72 | $0.00 | $127.72 | Paid |
| Totals | $320.00 | $198.40 | $40.00 | $158.40 | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- Patient account
- PA-397102
- 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-024636 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-25: MEDICARE-ADV-B (MA), effective 2024-11-01. | |
| Timely filing | Pass | Received 42 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 Associates2026-02-25 13:46
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 engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010913 | 2026-05-24 | Riverside Primary Care Associates | $265.00 | 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.