CLM-2026-026037
Heritage Primary Care Associates, Family Medicine. Service 2026-03-04 at office (POS 11). Received 2026-03-30.
Member
Resolved through the identity graph
- Member
- Stephanie Allen
- Member ID
- UHC-51810-47
- Date of birth
- 1995-11-20
- Identity
- Verified3 records, confidence 0.93
- Claim record
- CLMCLM-402049
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-2715
- Coverage period
- 2022-01-01 to present
- Deductible
- $435.45 of $500.0087%
- Out-of-pocket maximum
- $41.34 of $1,500.003%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 8400209101
- Network
- In network
- Rendering NPI
- 2486715842
- Location
- San Diego, CA · TIN 62-9200818
- 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 | 36415 | Venipuncture | — | 1 | 1 | $23.00 | $14.26 | $14.26 | $0.00 | Paid |
| Totals | $23.00 | $14.26 | $14.26 | $0.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-821817
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000848 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-03-04: SELECT-EPO (EPO), effective 2022-01-01. | |
| 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 Primary Care Associates (8400209101). | |
| 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 Primary Care Associates2026-03-04 10:48
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010410 | 2025-11-25 | Evergreen GI Associates | $1,403.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.