CLM-2026-010874
Heritage Primary Care Associates, Family Medicine. Service 2026-06-05 at office (POS 11). Received 2026-06-22.
Member
Resolved through the identity graph
- Member
- Anna Williams
- Member ID
- UHC-92716-76
- Date of birth
- 1985-11-05
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-425832
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9421
- Coverage period
- 2025-11-01 to 2026-06-22
- Deductible
- $329.33 of $1,000.0033%
- Out-of-pocket maximum
- $211.48 of $3,000.007%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 8400209101
- Network
- In network
- Rendering NPI
- 2130750120
- Location
- San Diego, CA · TIN 62-9200818
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $212.00 | $131.44 | $20.00 | $111.44 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $228.00 | $141.36 | $0.00 | $141.36 | Paid |
| Totals | $440.00 | $272.80 | $20.00 | $252.80 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-387632
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-002795 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-05: CORE-HMO (HMO), effective 2025-11-01, terms 2026-06-22. | |
| Timely filing | Pass | Received 17 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 Primary Care Associates (8400209101). | |
| 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 Associates2026-06-05 17:35
Patient seen for type 2 diabetes mellitus without complications.
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 engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021024 | 2026-03-11 | Lakeside Internal Medicine Associates | $311.00 | Approved |
| CLM-2026-027969 | 2025-12-08 | Northgate Bone and Joint Center | $10,190.00 | Denied |
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.