Claims workbench/CLM-2026-017675

Professional claim · CMS-1500 · EDI 837P

CLM-2026-017675

Heritage Primary Care Associates, Family Medicine. Service 2026-07-24 at office (POS 11). Received 2026-07-26.

Needs review

Billed

$315.00

3 lines

Allowed

$195.30

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Review

CO16

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Lori Parker
Member ID: UHC-06551-05
Date of birth: 1949-09-28
Identity: Verified3 records, confidence 0.99
Claim record: CLMCLM-400214
Relationship: Self, Chandler, AZ

Coverage and accumulators

Found by member ID

Plan: UNKNOWN PPO group GRP-9325
Coverage period: 2025-09-01 to present
Deductible: $425.24 of $1,500.0028%
Out-of-pocket maximum: $339.36 of $3,000.0011%
Copays: office $40.00, specialist $60.00, emergency $350.00
Physical therapy visits: 1 of 20 used

Provider

Billing and rendering

Billing provider: Heritage Primary Care Associates
Family Medicine · taxonomy 207Q00000X
NPI: 8400209101
Network: In network
Rendering NPI: 9400187693
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	99214	Office visit, established patient, moderate complexity	—	1	1	$267.00	$165.54	—	—	Review
2	90471	Immunization administration	—	1	1,2	$28.00	$17.36	—	—	Review
3	36415	Venipuncture	—	1	1	$20.00	$12.40	—	—	Review
Totals						$315.00	$195.30	—	—

Diagnoses (ICD-10-CM)

1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
2. E78.5 Hyperlipidemia, unspecified

Claim header

Patient account: PA-371079
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-028628 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-07-24: UNKNOWN (PPO), effective 2025-09-01.
Timely filing	Pass		Received 2 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	Review	CO16	Documentation incomplete: “Patient seen for type 2 diabetes mellitus without complications. Note dictated; signature ”. Claim lacks information needed for adjudication
High-dollar review	Pass		Within the auto-adjudication ceiling.

Evaluated 2026-10-22 12:44 under policy version 1. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Heritage Primary Care Associates2026-07-24 11:13
Patient seen for type 2 diabetes mellitus without complications. Note dictated; signature pending.
SystemSystem: Claims system2026-07-26 00:11
Rendering provider signature missing on the attached note. Development letter sent to provider.
AdministrativeExaminer: R. Patel (Claims Examiner II)2026-07-26 10:06
Member services inquiry logged on this claim; member asked about the status of payment.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-22 12:44
Completeness: Documentation incomplete: “Patient seen for type 2 diabetes mellitus without complications. Note dictated; signature ”.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-025083	2026-03-17	Mesa Family Practice	$236.00	Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

The rules engine left this claim for review. The AI adjudicator can read the evidence pack (lines, notes, attachments, coverage, history) and recommend an outcome with citations.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

PendedCO16scenario: Missing info

Development letter outstanding.

Review queue Member identity