CLM-2026-028216
Heritage Medical Group, Family Medicine. Service 2025-12-02 at office (POS 11). Received 2026-01-01.
Member
Resolved through the identity graph
- Member
- Diego West
- Member ID
- UHC-45695-22
- Date of birth
- 1962-07-26
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-403072
- Relationship
- Child, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-5435
- Coverage period
- 2024-12-01 to present
- Deductible
- $113.45 of $2,500.005%
- Out-of-pocket maximum
- $266.46 of $5,000.005%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 1536032422
- Network
- Out of network
- Rendering NPI
- 1832194967
- Location
- Denver, CO · TIN 49-9592909
- 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 | 59 | 1 | 1 | $12.00 | $5.40 | — | — | Review |
| 2 | 90471 | Immunization administration | 59 | 1 | 1,2 | $42.00 | $18.90 | — | — | Review |
| Totals | $54.00 | $24.30 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-253605
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000138 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-02: OPTIONS-PPO (PPO), effective 2024-12-01. | |
| Timely filing | Pass | Received 30 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Medical Group2025-12-02 18:13
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
- SystemSystem: Claims system2026-01-01 05:07
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-253605.pdf11 pages
Operative note describing procedures at two distinct anatomical sites.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
- AI recommendationApproved2026-10-21 14:05The claim is for a child with active coverage under the OPTIONS-PPO plan. The service was provided by an out-of-network provider, but the claim is within the timely filing limit and does not require prior authorization. The medical necessity is supported by the diagnosis, and the use of modifier 59 is justified by the operative note, which documents procedures at two distinct anatomical sites. The claim is complete and within the auto-adjudication ceiling.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:05 · ecb28df1
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031517 | 2026-05-25 | Sunrise Clinical Laboratories | $31.00 | Approved |
| CLM-2026-001528 | 2026-03-21 | Sunrise Clinical Laboratories | $115.00 | Needs review |
| CLM-2026-001527 | 2026-03-21 | Desert Reference Lab | $115.00 | Approved |
| CLM-2026-009190 | 2026-04-17 | Unity Reference Lab | $252.00 | Approved |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
The claim is for a child with active coverage under the OPTIONS-PPO plan. The service was provided by an out-of-network provider, but the claim is within the timely filing limit and does not require prior authorization. The medical necessity is supported by the diagnosis, and the use of modifier 59 is justified by the operative note, which documents procedures at two distinct anatomical sites. 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.