CLM-2026-011568
Heritage Medical Group, Internal Medicine. Service 2026-08-13 to 2026-08-15 at inpatient hospital (POS 21). Received 2026-09-07.
Member
Resolved through the identity graph
- Member
- Samantha Hicks
- Member ID
- UHC-27558-25
- Date of birth
- 1955-07-24
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-406446
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-2372
- Coverage period
- 2024-09-01 to 2026-03-13
- Deductible
- $2,149.00 of $2,500.0086%
- Out-of-pocket maximum
- $2,672.04 of $10,000.0027%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 9350331127
- Network
- In network
- Rendering NPI
- 4976723369
- Location
- Denver, CO · TIN 85-4450273
- 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 | $224.00 | $123.20 | — | — | DeniedCO27 |
| Totals | $224.00 | $123.20 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. J44.9 COPD, unspecified
- Patient account
- PA-700921
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-08-13 to 2026-08-17
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-043578 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-13 is after coverage terminated on 2026-03-13. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 23 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 Group2026-08-15 10:34
Patient seen for unspecified atrial fibrillation.
- SystemSystem: Claims system2026-09-07 05:03
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-09-07 12:32
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-700921.pdf5 pages
Itemised statement totalling $224.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-08-13 is after coverage terminated on 2026-03-13.
Other claims for this member
Same resolved identity
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
Service after coverage termination.