CLM-2026-018136
Heritage Medical Group, Family Medicine. Service 2026-04-23 at office (POS 11). Received 2026-05-02.
Member
Resolved through the identity graph
- Member
- Diane Collins
- Member ID
- UHC-37162-48
- Date of birth
- 1938-01-18
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-421941
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-4005
- Coverage period
- 2023-01-01 to present
- Deductible
- $1,506.88 of $2,500.0060%
- Out-of-pocket maximum
- $2,233.94 of $10,000.0022%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 1536032422
- Network
- Out of network
- Rendering NPI
- 4270261397
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $159.00 | $71.55 | — | — | DeniedCO204 |
| 2 | 99203 | Office visit, new patient, low complexity | 25 | 1 | 1 | $198.00 | $89.10 | — | — | DeniedCO204 |
| 3 | 90471 | Immunization administration | 25 | 1 | 1 | $31.00 | $13.95 | — | — | DeniedCO204 |
| Totals | $388.00 | $174.60 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-881811
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-009736 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-23: CORE-HMO (HMO), effective 2023-01-01. | |
| Timely filing | Pass | Received 9 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-018135, billed by a different provider. Possible duplicate |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Fail | CO204 | Billing provider 1536032422 is out of network and the HMO 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 Group2026-04-23 14:11
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-05-02 03:02
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-05-02 13:07
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Same member, date of service and procedures as CLM-2026-018135, billed by a different provider. Provider network: Billing provider 1536032422 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018135 | 2026-04-23 | Valley Family Practice | $388.00 | Approved |
| CLM-2026-011857 | 2026-03-14 | Riverside Clinical Laboratories | $125.00 | Approved |
| CLM-2026-024694 | 2026-01-30 | Summit Regional Medical Center | $2,797.00 | Needs review |
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
Different billing provider; separately payable.