CLM-2026-029940
Heritage Primary Care Associates, Family Medicine. Service 2026-08-15 at office (POS 11). Received 2026-09-11.
Member
Resolved through the identity graph
- Member
- Donna Guzman
- Member ID
- UHC-71147-44
- Date of birth
- 1947-11-14
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-424000
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3102
- Coverage period
- 2021-03-01 to present
- Deductible
- $1,286.60 of $3,500.0037%
- Out-of-pocket maximum
- $3,521.79 of $14,000.0025%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 2229159530
- Network
- In network
- Rendering NPI
- 9144025209
- Location
- Houston, TX · TIN 14-5202877
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $203.00 | $125.86 | $20.00 | $105.86 | Paid |
| 2 | 99395 | Preventive visit, 18-39 years | 25 | 1 | 1,2 | $270.00 | $167.40 | $0.00 | $167.40 | Paid |
| Totals | $473.00 | $293.26 | $20.00 | $273.26 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-592374
- 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-040543 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-15: CORE-HMO (HMO), effective 2021-03-01. | |
| Timely filing | Pass | Received 27 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 (2229159530). | |
| 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 Associates2026-08-15 14:41
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
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
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
Clean claim, priced at contract rate.