CLM-2026-027234
Heritage Primary Care Associates, Family Medicine. Service 2025-12-05 at office (POS 11). Received 2026-01-10.
Member
Resolved through the identity graph
- Member
- Charles Evans
- Member ID
- none on golden record
- Date of birth
- 1943-08-02
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-414369
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Eligibility
Provider
Billing and rendering
- Billing provider
- Heritage Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 8400209101
- Network
- In network
- Rendering NPI
- 8048817307
- 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 | 99203 | Office visit, new patient, low complexity | 59 | 1 | 1 | $223.00 | $138.26 | — | — | PendedN30 |
| 2 | 90471 | Immunization administration | 59 | 1 | 2 | $45.00 | $27.90 | — | — | PendedN30 |
| 3 | 36415 | Venipuncture | — | 1 | 2 | $20.00 | $12.40 | — | — | PendedN30 |
| Totals | $288.00 | $178.56 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- 3. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-157705
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-003011 (provisional, link confidence 1.00). | |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 36 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) | 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 Associates2025-12-05 11:19
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-01-10 02:34
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-157705.pdf18 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Eligibility: No coverage segment found for the member ID on this claim. Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
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
Bundled code pair; modifier 59 not supported by the operative note.