CLM-2026-023112
Heritage Primary Care Associates, Family Medicine. Service 2026-09-22 at office (POS 11). Received 2026-10-11.
Member
Resolved through the identity graph
- Member
- Melissa Tran
- Member ID
- UHC-46772-18
- Date of birth
- 1978-08-11
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-418411
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-5088
- Coverage period
- 2025-10-01 to present
- Deductible
- $127.84 of $1,000.0013%
- Out-of-pocket maximum
- $1,206.54 of $3,000.0040%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 3703132464
- Network
- In network
- Rendering NPI
- 5448749957
- Location
- Tempe, AZ · TIN 64-9033821
- 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 | 59 | 1 | 1 | $249.00 | $154.38 | — | — | Review |
| 2 | 99213 | Office visit, established patient, low complexity | 59 | 1 | 1 | $194.00 | $120.28 | — | — | Review |
| Totals | $443.00 | $274.66 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- Patient account
- PA-653571
- 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-013349 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-22: CORE-HMO (HMO), effective 2025-10-01. | |
| Timely filing | Pass | Received 19 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 Primary Care Associates (3703132464). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Primary Care Associates2026-09-22 12:05
Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
- SystemSystem: Claims system2026-10-11 06:04
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Medical recordrecords_PA-653571.pdf18 pages
Operative note describing procedures at two distinct anatomical sites.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009947 | 2026-10-08 | Canyon Counseling Center | $194.00 | Denied |
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
Modifier 59 supported: distinct anatomical site documented.