CLM-2026-019900
Heritage Family Practice, Family Medicine. Service 2026-01-22 at office (POS 11). Received 2026-07-08.
Member
Resolved through the identity graph
- Member
- Steven Nelson
- Member ID
- UHC-42830-85
- Date of birth
- 1964-01-11
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-410063
- Relationship
- Child, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8242
- Coverage period
- 2021-10-01 to present
- Deductible
- $99.25 of $2,500.004%
- Out-of-pocket maximum
- $3,353.58 of $7,500.0045%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 9531696935
- Network
- In network
- Rendering NPI
- 5535143106
- Location
- Scottsdale, AZ · TIN 58-2905850
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $325.00 | $201.50 | — | — | DeniedCO29 |
| 2 | 90471 | Immunization administration | 25 | 1 | 2 | $39.00 | $24.18 | — | — | DeniedCO29 |
| 3 | 36415 | Venipuncture | — | 1 | 2 | $25.00 | $15.50 | — | — | DeniedCO29 |
| Totals | $389.00 | $241.18 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-452215
- 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-024174 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-22: SELECT-EPO (EPO), effective 2021-10-01. | |
| Timely filing | Fail | CO29 | Received 167 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Family Practice (9531696935). | |
| 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 Family Practice2026-01-22 12:17
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-08 05:35
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 167 days after the last date of service (limit 90).
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
Received after the timely-filing limit.