CLM-2026-007115
Heritage Internal Medicine Associates, Internal Medicine. Service 2026-04-04 at office (POS 11). Received 2026-04-09.
Member
Resolved through the identity graph
- Member
- Sara Gordon
- Member ID
- UHC-17238-13
- Date of birth
- 1947-05-25
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-421093
- Relationship
- Child, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3434
- Coverage period
- 2022-08-01 to present
- Deductible
- $385.75 of $2,500.0015%
- Out-of-pocket maximum
- $1,954.34 of $5,000.0039%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6159930513
- Network
- In network
- Rendering NPI
- 4436815458
- Location
- Dallas, TX · TIN 90-9458167
- 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 | $81.00 | $50.22 | $20.00 | $30.22 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $251.00 | $155.62 | $0.00 | $155.62 | Paid |
| Totals | $332.00 | $205.84 | $20.00 | $185.84 | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-454971
- 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-018284 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-04-04: OPTIONS-PPO (PPO), effective 2022-08-01. | |
| Timely filing | Pass | Received 5 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 (6159930513). | |
| 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 Associates2026-04-04 18:58
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-2026-013535 | 2026-07-27 | Evergreen Orthopedic Specialists | $36,138.00 | Needs review |
| CLM-2026-009798 | 2026-02-14 | Cornerstone Internal Medicine Associates | $160.00 | 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.