CLM-2026-028250
Heritage Medical Group, Family Medicine. Service 2026-09-01 at office (POS 11). Received 2026-10-04.
Member
Resolved through the identity graph
- Member
- Douglas Henderson
- Member ID
- UHC-07476-51
- Date of birth
- 1997-01-10
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-413332
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6336
- Coverage period
- 2021-11-01 to 2026-07-19
- Deductible
- $513.43 of $1,000.0051%
- Out-of-pocket maximum
- $1,420.50 of $4,000.0036%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 1536032422
- Network
- Out of network
- Rendering NPI
- 6065535810
- 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 | — | 1 | 1 | $18.00 | $8.10 | — | — | DeniedCO27 |
| 2 | 99203 | Office visit, new patient, low complexity | 25 | 1 | 1 | $242.00 | $108.90 | — | — | DeniedCO27 |
| 3 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $149.00 | $67.05 | — | — | DeniedCO27 |
| Totals | $409.00 | $184.05 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-272170
- 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-001358 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-01 is after coverage terminated on 2026-07-19. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 33 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) | 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 Medical Group2026-09-01 18:52
Patient seen for low back pain, unspecified.
- SystemSystem: Claims system2026-10-04 06:41
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-10-04 14:15
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-09-01 is after coverage terminated on 2026-07-19. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009073 | 2026-07-24 | Harbor Rehabilitation Center | $271.00 | Denied |
| CLM-2026-012716 | 2026-03-08 | Meadow Dermatology Clinic | $218.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.