CLM-2026-032812
Heritage Primary Care Associates, Family Medicine. Service 2026-04-08 at office (POS 11). Received 2026-04-17.
Member
Resolved through the identity graph
- Member
- Willie Bailey
- Member ID
- UHC-45370-87
- Date of birth
- 1973-10-24
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-427770
- Relationship
- Spouse, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-5570
- Coverage period
- 2024-04-01 to present
- Deductible
- $803.53 of $1,000.0080%
- Out-of-pocket maximum
- $1,987.98 of $4,000.0050%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 2218360602
- Network
- In network
- Rendering NPI
- 8199510719
- Location
- Atlanta, GA · TIN 79-7884821
- 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 | 99395 | Preventive visit, 18-39 years | 59 | 1 | 1 | $316.00 | $195.92 | — | — | Review |
| 2 | 99213 | Office visit, established patient, low complexity | 59 | 1 | 1 | $175.00 | $108.50 | — | — | Review |
| Totals | $491.00 | $304.42 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-610091
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-012684 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-08: MEDICARE-ADV-B (MA), effective 2024-04-01. | |
| Timely filing | Pass | Received 9 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 (2218360602). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Associates2026-04-08 18:46
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-04-17 02:28
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Medical recordrecords_PA-610091.pdf4 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033051 | 2026-01-31 | Meadow Family Practice | $37.00 | Needs review |
| CLM-2026-033050 | 2026-01-31 | Meadow Family Practice | $37.00 | Approved |
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
Bundled code pair; modifier 59 not supported by the operative note.