CLM-2026-027560
Heritage Family Practice, Family Medicine. Service 2026-03-08 at office (POS 11). Received 2026-04-04.
Member
Resolved through the identity graph
- Member
- Jack Barnes
- Member ID
- UHC-58851-08
- Date of birth
- 1940-07-25
- Identity
- Verified7 records, confidence 0.99
- Claim record
- CLMCLM-424269
- Relationship
- Child, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-9378
- Coverage period
- 2025-12-01 to present
- Deductible
- $250.02 of $1,500.0017%
- Out-of-pocket maximum
- $933.50 of $3,000.0031%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 9531696935
- Network
- In network
- Rendering NPI
- 4770533808
- Location
- Scottsdale, AZ · TIN 58-2905850
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $285.00 | $176.70 | — | — | Review |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $277.00 | $171.74 | — | — | Review |
| Totals | $562.00 | $348.44 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- Patient account
- PA-940399
- Frequency code
- 7 (replacement)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 12 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-005830 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-08: NAVIGATE-HMO (HMO), effective 2025-12-01. | |
| Timely filing | Pass | Received 27 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Replacement claim | Review | REPL | Frequency code 7 replaces CLM-2026-027559; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Heritage Family Practice (9531696935). | |
| 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 Family Practice2026-03-08 10:35
Patient seen for acute upper respiratory infection, unspecified. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
- SystemSystem: Claims system2026-04-04 06:35
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-04-04 16:01
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Corrected claimcorrected_CLM-2026-027559.pdf1 page
Provider cover letter requesting replacement of CLM-2026-027559.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Replacement claim: Frequency code 7 replaces CLM-2026-027559; the original must be voided when this adjudicates.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-003255 | 2026-03-30 | Desert Internal Medicine Associates | $252.00 | Approved |
| CLM-2026-027559 | 2026-03-08 | Heritage Family Practice | $562.00 | Approved |
| CLM-2026-018147 | 2026-02-07 | Northgate Clinical Laboratories | $116.00 | Approved |
| CLM-2026-021469 | 2026-01-10 | Meadow Diagnostic Imaging | $160.00 | Denied |
| CLM-2026-000743 | 2026-01-06 | Summit Community Hospital | $1,769.00 | Approved |
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
Replacement claim supersedes the original.