CLM-2026-008969
Heritage Medical Group, Internal Medicine. Service 2026-09-07 at office (POS 11). Received 2026-10-06.
Member
Resolved through the identity graph
- Member
- Gary Garza
- Member ID
- UHC-15058-98
- Date of birth
- 1993-03-08
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-422537
- Relationship
- Child, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6777
- Coverage period
- 2022-12-01 to present
- Deductible
- $138.26 of $1,000.0014%
- Out-of-pocket maximum
- $843.01 of $3,000.0028%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 9350331127
- Network
- In network
- Rendering NPI
- 4215317288
- Location
- Denver, CO · TIN 85-4450273
- 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 | $114.00 | $70.68 | $30.00 | $40.68 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $295.00 | $182.90 | $0.00 | $182.90 | Paid |
| 3 | 99215 | Office visit, established patient, high complexity | 25 | 1 | 2 | $286.00 | $177.32 | $0.00 | $177.32 | Paid |
| Totals | $695.00 | $430.90 | $30.00 | $400.90 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-614867
- 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-044193 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-09-07: CHOICE-PLUS-PPO (PPO), effective 2022-12-01. | |
| Timely filing | Pass | Received 29 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 (9350331127). | |
| 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 Group2026-09-07 13:16
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-2026-008970 | 2026-09-07 | Heritage Medical Group | $695.00 | Needs review |
| CLM-2026-016291 | 2026-08-06 | Northgate Orthopedic Specialists | $229.00 | 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.