CLM-2026-022010
Heritage Medical Group, Family Medicine. Service 2026-02-11 at office (POS 11). Received 2026-03-01.
Member
Resolved through the identity graph
- Member
- John Vazquez
- Member ID
- UHC-53494-19
- Date of birth
- 1956-03-21
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-430175
- Relationship
- Spouse
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-6176
- Coverage period
- 2025-11-01 to present
- Deductible
- $126.50 of $1,500.008%
- Out-of-pocket maximum
- $815.93 of $4,500.0018%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 8291940475
- Network
- In network
- Rendering NPI
- 7551310908
- Location
- Mesa, AZ · TIN 22-3534685
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $204.00 | $126.48 | — | — | PendedIDQ |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $209.00 | $129.58 | — | — | PendedIDQ |
| Totals | $413.00 | $256.06 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- Patient account
- PA-357691
- 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 | Fail | IDQ | Member record is in open steward case CASE-001560; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-02-11: N/A (PPO), effective 2025-11-01. | |
| Timely filing | Pass | Received 18 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 Medical Group (8291940475). | |
| 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 Medical Group2026-02-11 14:46
Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-001560; payment withheld until the identity is confirmed.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.