CLM-2026-028482
Heritage Primary Care Associates, Family Medicine. Service 2025-12-11 at office (POS 11). Received 2026-05-07.
Member
Resolved through the identity graph
- Member
- Anthony Hoffman
- Member ID
- none on golden record
- Date of birth
- 1977-01-02
- Identity
- Verified2 records, confidence 0.93
- Claim record
- CLMCLM-402640
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by name and date of birth
- Plan
- MEDICARE-ADV-A MA group GRP-9953
- Coverage period
- 2021-08-01 to present
- Deductible
- $181.84 of $1,500.0012%
- Out-of-pocket maximum
- $991.95 of $4,500.0022%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 2218360602
- Network
- In network
- Rendering NPI
- 1106957180
- Location
- Atlanta, GA · TIN 79-7884821
- 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 | 90471 | Immunization administration | — | 1 | 1 | $42.00 | $26.04 | — | — | DeniedCO29 |
| 2 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $322.00 | $199.64 | — | — | DeniedCO29 |
| Totals | $364.00 | $225.68 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-860728
- 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-018895 (verified, link confidence 0.93). | |
| Eligibility | Note | Active on 2025-12-11: MEDICARE-ADV-A (MA), effective 2021-08-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Fail | CO29 | Received 147 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 (2218360602). | |
| 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 Associates2025-12-11 10:18
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-05-07 00:58
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Active on 2025-12-11: MEDICARE-ADV-A (MA), effective 2021-08-01. Coverage found by name and date of birth because the claim carried no usable member ID. Timely filing: Received 147 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
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
Received after the timely-filing limit.