CLM-2026-012889
Heritage Primary Care Associates, Family Medicine. Service 2026-06-11 at office (POS 11). Received 2026-07-15.
Member
Resolved through the identity graph
- Member
- Helen Kelly
- Member ID
- UHC-38298-68
- Date of birth
- 1976-06-06
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-430657
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group GRP-8186
- Coverage period
- 2024-11-01 to present
- Deductible
- $1,614.49 of $2,500.0065%
- Out-of-pocket maximum
- $1,983.48 of $5,000.0040%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 8400209101
- Network
- In network
- Rendering NPI
- 7766253166
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $192.00 | $119.04 | — | — | DeniedCO18 |
| 2 | 90471 | Immunization administration | — | 1 | 2 | $30.00 | $18.60 | — | — | DeniedCO18 |
| Totals | $222.00 | $137.64 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- 3. I10 Essential (primary) hypertension
- Patient account
- PA-369143
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-001114 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-11: UNKNOWN (PPO), effective 2024-11-01. | |
| Timely filing | Pass | Received 34 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-012888: 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 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 Associates2026-06-11 15:13
Patient seen for type 2 diabetes mellitus without complications.
- SystemSystem: Claims system2026-07-15 01:50
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-07-15 08:42
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-012888: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012888 | 2026-06-11 | Heritage Primary Care Associates | $222.00 | 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.