CLM-2026-014591
Heritage Medical Group, Internal Medicine. Service 2026-06-12 to 2026-06-16 at inpatient hospital (POS 21). Received 2026-07-02.
Member
Resolved through the identity graph
- Member
- Roger Hamilton
- Member ID
- UHC-09343-47
- Date of birth
- 1970-08-26
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-400849
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-0983
- Coverage period
- 2024-12-01 to present
- Deductible
- $1,712.98 of $2,500.0069%
- Out-of-pocket maximum
- $2,107.30 of $5,000.0042%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 9350331127
- Network
- In network
- Rendering NPI
- 7399807438
- 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 | $214.00 | $117.70 | $117.70 | $0.00 | Paid |
| Totals | $214.00 | $117.70 | $117.70 | $0.00 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-846441
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-06-12 to 2026-06-14
- 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-001016 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-12: MEDICARE-ADV-B (MA), effective 2024-12-01. | |
| Timely filing | Pass | Received 16 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 Group2026-06-16 12:33
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-846441.pdf8 pages
Itemised statement totalling $214.00 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019506 | 2026-09-21 | Mesa Behavioral Health | $2,288.00 | Needs review |
| CLM-2026-030229 | 2026-05-21 | Harbor Medical Group | $458.00 | Approved |
| CLM-2026-024837 | 2025-12-07 | Valley Community Hospital | $2,116.00 | Approved |
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.