Professional claim · CMS-1500 · EDI 837P
CLM-2026-021304
Heritage Family Practice, Family Medicine. Service 2026-06-07 at office (POS 11). Received 2026-07-17.
Denied
Billed
$336.00
2 lines
Allowed
$208.32
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 10% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Sarah Nguyen
- Member ID
- UHC-67677-60
- Date of birth
- 2004-01-18
- Identity
- Verified7 records, confidence 0.96
- Claim record
- CLMCLM-411838
- Relationship
- Spouse, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-8645
- Coverage period
- 2021-03-01 to 2026-05-14
- Deductible
- $909.85 of $1,500.0061%
- Out-of-pocket maximum
- $1,028.26 of $4,500.0023%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 9531696935
- Network
- In network
- Rendering NPI
- 2839331164
- 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 | $301.00 | $186.62 | — | — | DeniedCO27 |
| 2 | 90471 | Immunization administration | 25 | 1 | 1 | $35.00 | $21.70 | — | — | DeniedCO27 |
| Totals | $336.00 | $208.32 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
Claim header
- Patient account
- PA-117790
- 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-003899 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-07 is after coverage terminated on 2026-05-14. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 40 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 (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. |
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Heritage Family Practice2026-06-07 16:42
Follow-up for acute upper respiratory infection, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-17 04:25
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-06-07 is after coverage terminated on 2026-05-14.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020067 | 2026-07-31 | Pinecrest Cardiovascular Associates | $7,721.00 | Denied |
| CLM-2026-019671 | 2026-06-30 | Unity Primary Care Associates | $311.00 | Denied |
| CLM-2026-034635 | 2026-04-18 | Northgate Heart Institute | $269.00 | Approved |
| CLM-2026-019902 | 2026-04-05 | Meadow Primary Care Associates | $249.00 | Approved |
| CLM-2026-032433 | 2025-12-22 | Pinecrest Behavioral Health | $412.00 | Denied |
| CLM-2026-032432 | 2025-12-22 | Pinecrest Behavioral Health | $412.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Denied by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
DeniedCO27scenario: Coverage terminated
Service after coverage termination.