CLM-2026-014401
Heritage Medical Group, Family Medicine. Service 2026-08-20 at office (POS 11). Received 2026-08-30.
Member
Resolved through the identity graph
- Member
- Betty Sandoval
- Member ID
- UHC-13305-47
- Date of birth
- 1944-09-25
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-429962
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-2947
- Coverage period
- 2023-05-01 to 2026-05-26
- Deductible
- $2,107.39 of $3,500.0060%
- Out-of-pocket maximum
- $650.66 of $7,000.009%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 1536032422
- Network
- Out of network
- Rendering NPI
- 3897402673
- Location
- Denver, CO · TIN 49-9592909
- 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 | $194.00 | $87.30 | — | — | DeniedCO27 |
| Totals | $194.00 | $87.30 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-504265
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-023917 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-20 is after coverage terminated on 2026-05-26. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 10 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 | Fail | CO204 | Billing provider 1536032422 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Group2026-08-20 11:09
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-30 01:56
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-20 is after coverage terminated on 2026-05-26. Provider network: Billing provider 1536032422 is out of network and the EPO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-034438 | 2026-06-18 | Northgate Clinical Laboratories | $213.00 | Denied |
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.