CLM-2026-019576
Heritage Internal Medicine Associates, Internal Medicine. Service 2025-12-29 at office (POS 11). Received 2026-01-29.
Member
Resolved through the identity graph
- Member
- Peter Garrett
- Member ID
- UHC-36432-76
- Date of birth
- 1989-03-09
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-429008
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-7292
- Coverage period
- 2023-12-01 to present
- Deductible
- $1,278.14 of $3,500.0037%
- Out-of-pocket maximum
- $5,088.47 of $10,500.0048%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6159930513
- Network
- In network
- Rendering NPI
- 6943340219
- Location
- Dallas, TX · TIN 90-9458167
- 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 | $232.00 | $143.84 | $20.00 | $123.84 | Paid |
| 2 | 99215 | Office visit, established patient, high complexity | 25 | 1 | 1,2 | $336.00 | $208.32 | $0.00 | $208.32 | Paid |
| Totals | $568.00 | $352.16 | $20.00 | $332.16 | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-436635
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-008601 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-29: SELECT-EPO (EPO), effective 2023-12-01. | |
| Timely filing | Pass | Received 31 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 (6159930513). | |
| 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 Associates2025-12-29 18:22
Patient seen for type 2 diabetes mellitus with hyperglycemia.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.