CLM-2026-023359
Heritage Internal Medicine Associates, Internal Medicine. Service 2026-06-25 at office (POS 11). Received 2026-07-05.
Member
Resolved through the identity graph
- Member
- Gloria Gilbert
- Member ID
- UHC-67983-70
- Date of birth
- 1990-12-28
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-425690
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-8974
- Coverage period
- 2021-06-01 to 2026-02-09
- Deductible
- $3,126.30 of $3,500.0089%
- Out-of-pocket maximum
- $2,645.84 of $7,000.0038%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6689259359
- Network
- In network
- Rendering NPI
- 3659649347
- Location
- Miami, FL · TIN 57-4041631
- 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 | $40.00 | $24.80 | — | — | DeniedCO27 |
| Totals | $40.00 | $24.80 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-752763
- 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-019087 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-25 is after coverage terminated on 2026-02-09. Expenses incurred after coverage terminated |
| 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 (6689259359). | |
| 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 Associates2026-06-25 09:39
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-05 02:02
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-06-25 is after coverage terminated on 2026-02-09.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-000884 | 2026-05-28 | Harbor Digestive Health Center | $1,551.00 | Denied |
| CLM-2026-033898 | 2026-03-20 | Canyon Reference Lab | $51.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.