CLM-2026-009237
Heritage Internal Medicine Associates, Internal Medicine. Service 2026-01-21 to 2026-01-24 at inpatient hospital (POS 21). Received 2026-01-24.
Member
Resolved through the identity graph
- Member
- Donna Stephens
- Member ID
- UHC-67995-44
- Date of birth
- 1984-03-07
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-411671
- Relationship
- Spouse, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7778
- Coverage period
- 2023-02-01 to present
- Deductible
- $284.78 of $1,000.0028%
- Out-of-pocket maximum
- $236.21 of $4,000.006%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6689259359
- Network
- In network
- Rendering NPI
- 8853960994
- Location
- Miami, FL · TIN 57-4041631
- Authorisation / referral
- none / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $181.00 | $99.55 | $99.55 | $0.00 | Paid |
| Totals | $181.00 | $99.55 | $99.55 | $0.00 | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-181616
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-01-21 to 2026-01-23
- 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-007193 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-21: CHOICE-PLUS-PPO (PPO), effective 2023-02-01. | |
| Timely filing | Pass | Received 0 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 (6689259359). | |
| 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 Associates2026-01-24 12:36
Follow-up for type 2 diabetes mellitus with hyperglycemia. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-181616.pdf8 pages
Itemised statement totalling $181.00 across 1 line.
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-2026-015627 | 2026-07-16 | Pinecrest Physical Therapy | $195.00 | Approved |
| CLM-2026-008781 | 2026-02-23 | Heritage Orthopedic Specialists | $491.00 | 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.