CLM-2026-024147
Heritage Internal Medicine Associates, Internal Medicine. Service 2026-07-20 at office (POS 11). Received 2026-08-17.
Member
Resolved through the identity graph
- Member
- Katherine Robinson
- Member ID
- UHC-61326-69
- Date of birth
- 1975-05-01
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-404210
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-3360
- Coverage period
- 2021-07-01 to 2026-06-17
- Deductible
- $1,120.09 of $1,500.0075%
- Out-of-pocket maximum
- $887.24 of $4,500.0020%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6689259359
- Network
- In network
- Rendering NPI
- 8439325597
- Location
- Miami, FL · TIN 57-4041631
- Authorisation / referral
- none / REF537036
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 | $282.00 | $174.84 | — | — | DeniedCO27 |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 2 | $79.00 | $48.98 | — | — | DeniedCO27 |
| Totals | $361.00 | $223.82 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-488510
- 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 | Pass | Attached to MBR-013623 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-20 is after coverage terminated on 2026-06-17. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 28 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 Associates2026-07-20 15:05
Established patient presents with unspecified atrial fibrillation; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-17 05:36
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-08-17 08:04
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-07-20 is after coverage terminated on 2026-06-17.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019333 | 2026-01-30 | Mesa Physical Therapy | $126.00 | 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.