CLM-2026-030931
Heritage Family Practice, Family Medicine. Service 2026-06-09 at office (POS 11). Received 2026-06-17.
Member
Resolved through the identity graph
- Member
- Barbara Weber
- Member ID
- UHC-24739-99
- Date of birth
- 1948-01-25
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-428900
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-5437
- Coverage period
- 2023-12-01 to present
- Deductible
- $435.00 of $500.0087%
- Out-of-pocket maximum
- $471.53 of $1,000.0047%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 3586851693
- Network
- In network
- Rendering NPI
- 4074401207
- Location
- Scottsdale, AZ · TIN 98-1410500
- 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 | $32.00 | $19.84 | $19.84 | $0.00 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | 25 | 1 | 1 | $150.00 | $93.00 | $0.00 | $93.00 | Paid |
| Totals | $182.00 | $112.84 | $19.84 | $93.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-758414
- 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-009229 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-09: OPTIONS-PPO (PPO), effective 2023-12-01. | |
| Timely filing | Pass | Received 8 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 Family Practice (3586851693). | |
| 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 Family Practice2026-06-09 09:38
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004445 | 2026-09-11 | Unity Digestive Health Center | $306.00 | Needs review |
| CLM-2026-004444 | 2026-09-11 | Unity Digestive Health Center | $306.00 | Approved |
| CLM-2026-030907 | 2026-02-18 | Riverside Primary Care Associates | $61.00 | Approved |
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.