CLM-2026-011839
Heritage Medical Group, Internal Medicine. Service 2026-09-13 to 2026-09-14 at inpatient hospital (POS 21). Received 2026-09-29.
Member
Resolved through the identity graph
- Member
- Amber Wells
- Member ID
- UHC-80479-97
- Date of birth
- 1953-04-11
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-423452
- Relationship
- Spouse, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-6435
- Coverage period
- 2022-03-01 to present
- Deductible
- $697.45 of $2,500.0028%
- Out-of-pocket maximum
- $3,397.11 of $7,500.0045%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 9350331127
- Network
- In network
- Rendering NPI
- 5075886346
- 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 | $163.00 | $89.65 | — | — | DeniedCO18 |
| Totals | $163.00 | $89.65 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-788875
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-09-13 to 2026-09-16
- 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-002456 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-09-13: OPTIONS-PPO (PPO), effective 2022-03-01. | |
| Timely filing | Pass | Received 15 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-011838: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| 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 Group2026-09-14 18:11
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-29 01:11
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-09-29 12:50
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-788875.pdf7 pages
Itemised statement totalling $163.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-011838: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011838 | 2026-09-13 | Heritage Medical Group | $163.00 | Approved |
| CLM-2026-019682 | 2026-04-16 | Evergreen Primary Care Associates | $33.00 | Needs review |
| CLM-2026-019681 | 2026-04-16 | Evergreen Medical Group | $33.00 | 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
Exact duplicate of an earlier submission.