CLM-2026-012633
Heritage Medical Group, Internal Medicine. Service 2026-01-21 to 2026-01-24 at inpatient hospital (POS 21). Received 2026-02-14.
Member
Resolved through the identity graph
- Member
- Cynthia Nelson
- Member ID
- UHC-19090-03
- Date of birth
- 1993-10-25
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-401823
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6133
- Coverage period
- 2024-11-01 to 2026-07-16
- Deductible
- $20.27 of $1,000.002%
- Out-of-pocket maximum
- $1,426.68 of $3,000.0048%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 9350331127
- Network
- In network
- Rendering NPI
- 9352000175
- 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 | $175.00 | $96.25 | $96.25 | $0.00 | Paid |
| Totals | $175.00 | $96.25 | $96.25 | $0.00 | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-725824
- 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-011202 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-21: CHOICE-PLUS-PPO (PPO), effective 2024-11-01, terms 2026-07-16. | |
| Timely filing | Pass | Received 21 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 Group2026-01-24 17:50
Patient seen for type 2 diabetes mellitus with hyperglycemia.
Attachments
Documents received with the claim
- Itemized billitemized_PA-725824.pdf7 pages
Itemised statement totalling $175.00 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
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.