CLM-2026-022350
Heritage Medical Group, Family Medicine. Service 2026-01-17 at office (POS 11). Received 2026-01-30.
Member
Resolved through the identity graph
- Member
- Stephanie Cole
- Member ID
- UHC-53992-59
- Date of birth
- 1997-09-22
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-401921
- Relationship
- Spouse, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-3050
- Coverage period
- 2022-06-01 to present
- Deductible
- $405.87 of $3,500.0012%
- Out-of-pocket maximum
- $741.32 of $10,500.007%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 8291940475
- Network
- In network
- Rendering NPI
- 6965416608
- 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 | $236.00 | $146.32 | $40.00 | $106.32 | Paid |
| Totals | $236.00 | $146.32 | $40.00 | $106.32 | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-271112
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-009012 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-17: SELECT-EPO (EPO), effective 2022-06-01. | |
| Timely filing | Pass | Received 13 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 Group2026-01-17 09:56
Follow-up for low back pain, 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 system2026-01-30 01:35
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-01-30 11:09
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-271112.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 engineApproved2026-10-21 13:43Clean 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.