CLM-2026-017445
Heritage Primary Care Associates, Family Medicine. Service 2026-07-15 at office (POS 11). Received 2026-08-26.
Member
Resolved through the identity graph
- Member
- Mary Morales
- Member ID
- UHC-10683-37
- Date of birth
- 1998-04-27
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-410921
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-5513
- Coverage period
- 2022-12-01 to 2026-06-06
- Deductible
- $435.64 of $3,500.0012%
- Out-of-pocket maximum
- $3,419.25 of $14,000.0024%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 8400209101
- Network
- In network
- Rendering NPI
- 7938703569
- 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 | $205.00 | $127.10 | — | — | DeniedCO27 |
| 2 | 99395 | Preventive visit, 18-39 years | — | 1 | 2 | $243.00 | $150.66 | — | — | DeniedCO27 |
| Totals | $448.00 | $277.76 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-360155
- 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-028457 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-15 is after coverage terminated on 2026-06-06. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 42 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 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 Associates2026-07-15 09:43
Follow-up for acute upper respiratory infection, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-26 06:32
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-08-26 09:45
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 12:44Eligibility: Date of service 2026-07-15 is after coverage terminated on 2026-06-06.
Other claims for this member
Same resolved identity
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.