CLM-2026-024501
Heritage Medical Group, Internal Medicine. Service 2026-02-06 at office (POS 11). Received 2026-03-04.
Member
Resolved through the identity graph
- Member
- Wayne Cruz
- Member ID
- UHC-31174-70
- Date of birth
- 1964-09-07
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-427829
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-9701
- Coverage period
- 2021-09-01 to 2026-01-13
- Deductible
- $606.88 of $1,000.0061%
- Out-of-pocket maximum
- $1,738.93 of $4,000.0043%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 5190573977
- Network
- In network
- Rendering NPI
- 3966538720
- Location
- Austin, TX · TIN 10-1675475
- 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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $119.00 | $73.78 | — | — | DeniedCO27 |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 1,2 | $301.00 | $186.62 | — | — | DeniedCO27 |
| 3 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $279.00 | $172.98 | — | — | DeniedCO27 |
| Totals | $699.00 | $433.38 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- 3. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-672720
- 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-017313 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-02-06 is after coverage terminated on 2026-01-13. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 26 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 (5190573977). | |
| 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 Group2026-02-06 14:50
Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-03-04 03:41
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-03-04 12:41
Called the provider office; awaiting documentation.
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 2026-02-06 is after coverage terminated on 2026-01-13.
Other claims for this member
Same resolved identity
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.