CLM-2026-006746
Heritage Primary Care Associates, Family Medicine. Service 2026-08-17 at outpatient hospital (POS 22). Received 2026-08-30.
Member
Resolved through the identity graph
- Member
- Juhn Simpson
- Member ID
- UHC-44690-09
- Date of birth
- 1959-02-04
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-401480
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-5037
- Coverage period
- 2021-01-01 to 2026-01-14
- Deductible
- $1,050.44 of $3,500.0030%
- Out-of-pocket maximum
- $2,446.90 of $7,000.0035%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 5397655734
- Network
- In network
- Rendering NPI
- 4605183191
- Location
- Tampa, FL · TIN 61-8345625
- Authorisation / referral
- PA2025575892 / 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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $3,125.00 | $1,718.75 | — | — | DeniedCO27 |
| Totals | $3,125.00 | $1,718.75 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-434626
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-040028 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-17 is after coverage terminated on 2026-01-14. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 13 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025575892 on file for 70553. | |
| Provider network | Pass | In-network provider Heritage Primary Care Associates (5397655734). | |
| Medical necessity | Review | CO50 | 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity. Not medically necessary per payer policy |
| 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 Primary Care Associates2026-08-17 10:36
Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-30 04:23
Attachments
Documents received with the claim
- Prior auth letterPA2025575892_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-08-17 to 2026-11-15.
- Itemized billitemized_PA-434626.pdf7 pages
Itemised statement totalling $3125.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-08-17 is after coverage terminated on 2026-01-14. Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
Other claims for this member
Same resolved identity
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
Service after coverage termination.