CLM-2026-017708
Heritage Internal Medicine Associates, Internal Medicine. Service 2026-10-11 at office (POS 11). Received 2026-10-18.
Member
Resolved through the identity graph
- Member
- Noah Rogers
- Member ID
- UHC-89314-56
- Date of birth
- 1958-04-08
- Identity
- Verified3 records, confidence 0.98
- Claim record
- CLMCLM-417699
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3872
- Coverage period
- 2025-02-01 to 2026-02-17
- Deductible
- $191.73 of $500.0038%
- Out-of-pocket maximum
- $468.90 of $1,500.0031%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6689259359
- Network
- In network
- Rendering NPI
- 9681564131
- Location
- Miami, FL · TIN 57-4041631
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $79.00 | $48.98 | — | — | DeniedCO27 |
| 2 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $89.00 | $55.18 | — | — | DeniedCO27 |
| Totals | $168.00 | $104.16 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-988507
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-005517 (verified, link confidence 0.98). | |
| Eligibility | Fail | CO27 | Date of service 2026-10-11 is after coverage terminated on 2026-02-17. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 7 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 Internal Medicine Associates (6689259359). | |
| 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 Internal Medicine Associates2026-10-11 13:14
Established patient presents with chronic kidney disease, stage 3 unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-10-18 00:38
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 2026-10-11 is after coverage terminated on 2026-02-17.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002226 | 2025-12-25 | Cornerstone Internal Medicine Associates | $177.00 | 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
Service after coverage termination.