CLM-2026-006964
Heritage Medical Group, Internal Medicine. Service 2025-12-19 at office (POS 11). Received 2026-01-09.
Member
Resolved through the identity graph
- Member
- Robert Price
- Member ID
- UHC-60747-77
- Date of birth
- 1967-04-12
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-419942
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-6023
- Coverage period
- 2021-03-01 to present
- Deductible
- $800.34 of $1,000.0080%
- Out-of-pocket maximum
- $540.90 of $3,000.0018%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 5190573977
- Network
- In network
- Rendering NPI
- 8059136670
- Location
- Austin, TX · TIN 10-1675475
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $81.00 | $50.22 | $25.00 | $25.22 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | 25 | 1 | 1 | $242.00 | $150.04 | $0.00 | $150.04 | Paid |
| Totals | $323.00 | $200.26 | $25.00 | $175.26 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-902345
- 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-002869 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-12-19: SELECT-EPO (EPO), effective 2021-03-01. | |
| Timely filing | Pass | Received 21 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 Medical Group (5190573977). | |
| 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 Group2025-12-19 10:07
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
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-2026-001927 | 2026-07-20 | Harbor Medical Group | $410.00 | Approved |
| CLM-2026-019741 | 2026-07-02 | Unity Clinical Laboratories | $32.00 | Approved |
| CLM-2026-008406 | 2026-07-08 | Pinecrest Reference Lab | $56.00 | 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.