CLM-2026-021146
Heritage Internal Medicine Associates, Internal Medicine. Service 2026-02-03 at office (POS 11). Received 2026-02-13.
Member
Resolved through the identity graph
- Member
- Jose Dean
- Member ID
- UHC-55923-79
- Date of birth
- 2007-07-09
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-420154
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3457
- Coverage period
- 2023-06-01 to present
- Deductible
- $578.12 of $1,000.0058%
- Out-of-pocket maximum
- $23.41 of $2,000.001%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- 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
- 7729569476
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $58.00 | $35.96 | $25.00 | $10.96 | Paid |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 2 | $288.00 | $178.56 | $0.00 | $178.56 | Paid |
| 3 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $265.00 | $164.30 | $0.00 | $164.30 | Paid |
| Totals | $611.00 | $378.82 | $25.00 | $353.82 | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- Patient account
- PA-750302
- 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-012853 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-03: CHOICE-PLUS-PPO (PPO), effective 2023-06-01. | |
| Timely filing | Pass | Received 10 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 Associates2026-02-03 13:17
Follow-up for copd, unspecified. Plan discussed, medications reconciled. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-02-13 05:32
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-02-13 15:27
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-750302.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
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
Authorisation must be confirmed with UM before payment.