CLM-2026-030340
Heritage Internal Medicine Associates, Internal Medicine. Service 2025-12-26 at office (POS 11). Received 2026-01-07.
Member
Resolved through the identity graph
- Member
- William Allen
- Member ID
- UHC-46233-87
- Date of birth
- 1953-06-12
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-414468
- Relationship
- Spouse, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4503
- Coverage period
- 2023-04-01 to present
- Deductible
- $79.48 of $1,000.008%
- Out-of-pocket maximum
- $42.44 of $4,000.001%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6689259359
- Network
- In network
- Rendering NPI
- 2879256966
- Location
- Miami, FL · TIN 57-4041631
- 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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $102.00 | $63.24 | $25.00 | $38.24 | Paid |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 2 | $46.00 | $28.52 | $0.00 | $28.52 | Paid |
| Totals | $148.00 | $91.76 | $25.00 | $66.76 | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- Patient account
- PA-746221
- 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-002181 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-26: SELECT-EPO (EPO), effective 2023-04-01. | |
| Timely filing | Pass | Received 12 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 Internal Medicine Associates (6689259359). | |
| 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 Internal Medicine Associates2025-12-26 18:22
Patient seen for type 2 diabetes mellitus with hyperglycemia.
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-003782 | 2026-02-28 | Lakeside Imaging Center | $172.00 | Approved |
| CLM-2026-006309 | 2026-01-25 | Desert Medical Group | $288.00 | Approved |
| CLM-2026-007633 | 2025-10-05 | Canyon Reference Lab | $152.00 | Denied |
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.