Claims workbench/CLM-2026-008791
Professional claim · CMS-1500 · EDI 837P

CLM-2026-008791

Heritage Primary Care Associates, Family Medicine. Service 2025-10-24 at office (POS 11). Received 2026-04-16.

Denied
Billed
$25.00
1 line
Allowed
$15.50
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 10% coinsurance
Rules engine
Deny
CO29
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Ryan Little
Member ID
UHC-91652-15
Date of birth
1995-06-13
Identity
Verified2 records, confidence 0.97
Claim record
CLMCLM-403008
Relationship
Child, Eden Prairie, MN

Coverage and accumulators

Found by member ID

Plan
SELECT-EPO EPO group GRP-6413
Coverage period
2023-12-01 to present
Deductible
$1,981.69 of $3,500.0057%
Out-of-pocket maximum
$122.70 of $14,000.001%
Copays
office $25.00, specialist $60.00, emergency $350.00
Physical therapy visits
18 of 20 used

Provider

Billing and rendering

Billing provider
Heritage Primary Care Associates
Family Medicine · taxonomy 207Q00000X
NPI
2218360602
Network
In network
Rendering NPI
7815410957
Location
Atlanta, GA · TIN 79-7884821
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
136415Venipuncture—11$25.00$15.50——DeniedCO29
Totals$25.00$15.50——
Diagnoses (ICD-10-CM)
  • 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
Claim header
Patient account
PA-625304
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-003074 (verified, link confidence 0.97).
EligibilityPassActive on 2025-10-24: SELECT-EPO (EPO), effective 2023-12-01.
Timely filingFailCO29Received 174 days after the last date of service (limit 90).
Time limit for filing has expired
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Heritage Primary Care Associates (2218360602).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Heritage Primary Care Associates2025-10-24 13:57

    Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled.

  • SystemSystem: Claims system2026-04-16 00:35

    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

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineDenied2026-10-22 12:44
    Timely filing: Received 174 days after the last date of service (limit 90).

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

DeniedCO29scenario: Late filing

Received after the timely-filing limit.

Review queueMember identity