CLM-2026-009647
Heritage Internal Medicine Associates, Internal Medicine. Service 2025-07-31 at office (POS 11). Received 2026-03-02.
Member
Resolved through the identity graph
- Member
- Bradley Carroll
- Member ID
- UHC-60033-71
- Date of birth
- 2004-12-02
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-400430
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-0258
- Coverage period
- 2021-07-01 to present
- Deductible
- $288.60 of $3,500.008%
- Out-of-pocket maximum
- $1,535.37 of $10,500.0015%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6689259359
- Network
- In network
- Rendering NPI
- 9684984773
- Location
- Miami, FL · TIN 57-4041631
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $71.00 | $44.02 | — | — | DeniedCO29 |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $308.00 | $190.96 | — | — | DeniedCO29 |
| Totals | $379.00 | $234.98 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-743017
- 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-016939 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-07-31: MEDICARE-ADV-A (MA), effective 2021-07-01. | |
| Timely filing | Fail | CO29 | Received 214 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 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 Associates2025-07-31 09:21
Established patient presents with unspecified atrial fibrillation; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-03-02 06:50
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-03-02 17:26
Reviewed with the member's history on file. Holding for the items listed above.
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 214 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021880 | 2026-06-30 | Mesa Physical Therapy | $354.00 | Denied |
| CLM-2026-032286 | 2026-01-22 | Sunrise GI Associates | $1,738.00 | 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.