CLM-2026-020739
Heritage Primary Care Associates, Family Medicine. Service 2026-05-13 at office (POS 11). Received 2026-06-05.
Member
Resolved through the identity graph
- Member
- Catherine Richardson
- Member ID
- UHC-15592-78
- Date of birth
- 2005-08-26
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-403849
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-7948
- Coverage period
- 2022-10-01 to 2026-02-12
- Deductible
- $115.61 of $1,500.008%
- Out-of-pocket maximum
- $1,342.93 of $4,500.0030%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 5397655734
- Network
- In network
- Rendering NPI
- 6908151817
- Location
- Tampa, FL · TIN 61-8345625
- 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 | $148.00 | $91.76 | — | — | DeniedCO27 |
| 2 | 36415 | Venipuncture | — | 1 | 1,2 | $21.00 | $13.02 | — | — | DeniedCO27 |
| Totals | $169.00 | $104.78 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-408310
- 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-033724 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-13 is after coverage terminated on 2026-02-12. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 23 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 (5397655734). | |
| 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 Associates2026-05-13 14:29
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-06-05 03:13
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 2026-05-13 is after coverage terminated on 2026-02-12.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-000324 | 2026-04-27 | Heritage Imaging Center | $1,612.00 | Denied |
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.