CLM-2026-018704
Heritage Primary Care Associates, Family Medicine. Service 2026-10-07 at office (POS 11). Received 2026-10-15.
Member
Resolved through the identity graph
- Member
- Emily Lucas
- Member ID
- UHC-12704-17
- Date of birth
- 2002-08-23
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-421844
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-1408
- Coverage period
- 2024-05-01 to 2026-07-15
- Deductible
- $164.53 of $500.0033%
- Out-of-pocket maximum
- $276.43 of $1,000.0028%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 3703132464
- Network
- In network
- Rendering NPI
- 9972668278
- Location
- Tempe, AZ · TIN 64-9033821
- 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 | $201.00 | $124.62 | — | — | DeniedCO27 |
| Totals | $201.00 | $124.62 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-992647
- 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-033909 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-10-07 is after coverage terminated on 2026-07-15. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 8 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 (3703132464). | |
| 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 Associates2026-10-07 13:40
Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-10-15 05:59
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-10-15 17:55
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 engineDenied2026-10-21 13:43Eligibility: Date of service 2026-10-07 is after coverage terminated on 2026-07-15.
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.