CLM-2026-020924
Heritage Family Practice, Family Medicine. Service 2026-06-22 at office (POS 11). Received 2026-08-04.
Member
Resolved through the identity graph
- Member
- Camila Hanson
- Member ID
- UHC-25006-69
- Date of birth
- 2008-01-09
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-425165
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-4874
- Coverage period
- 2023-12-01 to 2026-01-19
- Deductible
- $847.44 of $1,500.0056%
- Out-of-pocket maximum
- $289.66 of $3,000.0010%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 3586851693
- Network
- In network
- Rendering NPI
- 2559101235
- Location
- Scottsdale, AZ · TIN 98-1410500
- 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 | $179.00 | $110.98 | — | — | DeniedCO27 |
| 2 | 99214 | Office visit, established patient, moderate complexity | 25 | 1 | 1,2 | $260.00 | $161.20 | — | — | DeniedCO27 |
| 3 | 90471 | Immunization administration | — | 1 | 2 | $32.00 | $19.84 | — | — | DeniedCO27 |
| Totals | $471.00 | $292.02 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-188334
- 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-015779 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-22 is after coverage terminated on 2026-01-19. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 43 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 Family Practice (3586851693). | |
| 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 Practice2026-06-22 14:14
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-04 05:04
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-08-04 09:34
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 12:44Eligibility: Date of service 2026-06-22 is after coverage terminated on 2026-01-19.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016597 | 2026-07-07 | Mesa Medical Group | $471.00 | 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.