CLM-2026-008191
Heritage Primary Care Associates, Family Medicine. Service 2026-05-07 at office (POS 11). Received 2026-09-29.
Member
Resolved through the identity graph
- Member
- Anthony Harris
- Member ID
- UHC-93261-88
- Date of birth
- 2002-11-20
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-427765
- Relationship
- Spouse, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4078
- Coverage period
- 2023-04-01 to present
- Deductible
- $1,593.63 of $2,500.0064%
- Out-of-pocket maximum
- $1,179.29 of $5,000.0024%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 3703132464
- Network
- In network
- Rendering NPI
- 7780618881
- Location
- Tempe, AZ · TIN 64-9033821
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $231.00 | $143.22 | — | — | DeniedCO29 |
| Totals | $231.00 | $143.22 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- Patient account
- PA-870749
- 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-025039 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-05-07: SELECT-EPO (EPO), effective 2023-04-01. | |
| Timely filing | Fail | CO29 | Received 145 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Primary Care Associates (3703132464). | |
| 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 Primary Care Associates2026-05-07 17:31
Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-29 06:54
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 145 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032365 | 2026-04-17 | Northgate Primary Care Associates | $253.00 | Denied |
| CLM-2026-000649 | 2026-03-31 | Canyon Primary Care Associates | $48.00 | 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
Received after the timely-filing limit.