CLM-2026-006703
Heritage Medical Group, Family Medicine. Service 2026-05-21 at office (POS 11). Received 2026-06-28.
Member
Resolved through the identity graph
- Member
- Walter Espinoza
- Member ID
- UHC-40017-55
- Date of birth
- 1976-05-06
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-405432
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-1008
- Coverage period
- 2023-03-01 to present
- Deductible
- $1,727.31 of $2,500.0069%
- Out-of-pocket maximum
- $1,678.90 of $5,000.0034%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 1536032422
- Network
- Out of network
- Rendering NPI
- 9394076290
- Location
- Denver, CO · TIN 49-9592909
- 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 | 36415 | Venipuncture | — | 1 | 1 | $21.00 | $9.45 | — | — | DeniedCO204 |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 2 | $166.00 | $74.70 | — | — | DeniedCO204 |
| Totals | $187.00 | $84.15 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-113965
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-028988 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-05-21: NAVIGATE-HMO (HMO), effective 2023-03-01. | |
| Timely filing | Pass | Received 38 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 | Fail | CO204 | Billing provider 1536032422 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Group2026-05-21 17:53
Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-28 06:18
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 1536032422 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011275 | 2026-07-31 | Summit Heart Institute | $618.00 | Approved |
| CLM-2026-016745 | 2026-03-22 | Sunrise Behavioral Health | $216.00 | 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
No out-of-network benefit on this plan.