CLM-2026-029872
Heritage Primary Care Associates, Family Medicine. Service 2026-03-04 at office (POS 11). Received 2026-04-14.
Member
Resolved through the identity graph
- Member
- Kelly Park
- Member ID
- none on golden record
- Date of birth
- 1961-01-15
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-408147
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- OPTIONS-PPO PPO group GRP-1200
- Coverage period
- 2022-06-01 to present
- Deductible
- $2,751.76 of $3,500.0079%
- Out-of-pocket maximum
- $5,222.42 of $14,000.0037%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 8400209101
- Network
- In network
- Rendering NPI
- 7544973846
- Location
- San Diego, CA · TIN 62-9200818
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $217.00 | $134.54 | — | — | PendedIDQ |
| 2 | 99395 | Preventive visit, 18-39 years | 25 | 1 | 2 | $313.00 | $194.06 | — | — | PendedIDQ |
| Totals | $530.00 | $328.60 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-678557
- 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 | Fail | IDQ | Member record is in open steward case CASE-000617; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-03-04: OPTIONS-PPO (PPO), effective 2022-06-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 41 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 Primary Care Associates (8400209101). | |
| 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 Associates2026-03-04 13:07
Established patient presents with acute upper respiratory infection, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-000617; payment withheld until the identity is confirmed. Eligibility: Active on 2026-03-04: OPTIONS-PPO (PPO), effective 2022-06-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
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
Clean claim, priced at contract rate.