CLM-2026-024614
Heritage Primary Care Associates, Family Medicine. Service 2026-01-12 at office (POS 11). Received 2026-01-15.
Member
Resolved through the identity graph
- Member
- Thomas Carer
- Member ID
- UHC-49760-79
- Date of birth
- 2004-04-14
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-423843
- Relationship
- Child, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-5285
- Coverage period
- 2021-11-01 to present
- Deductible
- $1,049.11 of $3,500.0030%
- Out-of-pocket maximum
- $5,348.94 of $14,000.0038%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 2218360602
- Network
- In network
- Rendering NPI
- 5741457167
- Location
- Atlanta, GA · TIN 79-7884821
- 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 | 59 | 1 | 1 | $299.00 | $185.38 | — | — | Review |
| 2 | 36415 | Venipuncture | 59 | 1 | 2 | $12.00 | $7.44 | — | — | Review |
| Totals | $311.00 | $192.82 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. M54.50 Low back pain, unspecified
- 3. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-313585
- 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-004562 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-12: SELECT-EPO (EPO), effective 2021-11-01. | |
| Timely filing | Pass | Received 3 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 (2218360602). | |
| 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 Associates2026-01-12 09:17
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
- SystemSystem: Claims system2026-01-15 03:10
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-313585.pdf16 pages
Operative note describing procedures at two distinct anatomical sites.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
- AI recommendationApproved2026-10-23 19:13The claim is for an in-network provider and the member is eligible. The service was timely filed and there are no duplicate claims. The claim does not require prior authorization and the provider is in-network. The medical necessity is supported by the diagnosis. The NCCI edit flagged the use of modifier 59 on a normally bundled code pair, but the operative note documents a distinct procedural service at a separate anatomical site, justifying the use of the modifier. The claim is complete and within the auto-adjudication ceiling.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-23 19:13 · afa2babf
Other claims for this member
Same resolved identity
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
The claim is for an in-network provider and the member is eligible. The service was timely filed and there are no duplicate claims. The claim does not require prior authorization and the provider is in-network. The medical necessity is supported by the diagnosis. The NCCI edit flagged the use of modifier 59 on a normally bundled code pair, but the operative note documents a distinct procedural service at a separate anatomical site, justifying the use of the modifier. The claim is complete and within the auto-adjudication ceiling.
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.