CLM-2026-029369
Heritage Medical Group, Internal Medicine. Service 2026-02-02 at office (POS 11). Received 2026-02-15.
Member
Resolved through the identity graph
- Member
- Hiroshi Rogers
- Member ID
- UHC-98848-91
- Date of birth
- 1986-08-07
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-413084
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-4163
- Coverage period
- 2021-01-01 to present
- Deductible
- $101.31 of $3,500.003%
- Out-of-pocket maximum
- $4,691.28 of $14,000.0034%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 5190573977
- Network
- In network
- Rendering NPI
- 6730144873
- Location
- Austin, TX · TIN 10-1675475
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $52.00 | $32.24 | $25.00 | $7.24 | Paid |
| 2 | 93000 | Electrocardiogram with interpretation | — | 1 | 2 | $61.00 | $37.82 | $0.00 | $37.82 | Paid |
| Totals | $113.00 | $70.06 | $25.00 | $45.06 | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-342890
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-013281 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-02-02: OPTIONS-PPO (PPO), effective 2021-01-01. | |
| Timely filing | Pass | Received 13 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 Medical Group (5190573977). | |
| 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 Group2026-02-02 12:21
Follow-up for copd, unspecified. Plan discussed, medications reconciled. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-02-15 01:40
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-342890.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-000752 | 2026-08-27 | Unity Medical Group | $157.00 | Approved |
| CLM-2026-031787 | 2026-06-21 | Harbor Medical Group | $2,407.00 | Needs review |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Authorisation must be confirmed with UM before payment.