CLM-2026-032879
Heritage Family Practice, Family Medicine. Service 2026-06-29 at office (POS 11). Received 2026-08-20.
Member
Resolved through the identity graph
- Member
- Jessica Wang
- Member ID
- UHC-04085-61
- Date of birth
- 2003-01-20
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-414167
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-8313
- Coverage period
- 2021-04-01 to present
- Deductible
- $1,367.76 of $2,500.0055%
- Out-of-pocket maximum
- $1,221.52 of $10,000.0012%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 3586851693
- Network
- In network
- Rendering NPI
- 1079766865
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $152.00 | $94.24 | — | — | DeniedCO18 |
| Totals | $152.00 | $94.24 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-815985
- 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-019973 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-29: MEDICARE-ADV-A (MA), effective 2021-04-01. | |
| Timely filing | Pass | Received 52 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-032878: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| 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 Practice2026-06-29 15:42
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-20 04:37
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-032878: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032878 | 2026-06-29 | Heritage Family Practice | $152.00 | Approved |
| CLM-2026-028109 | 2026-05-20 | Meadow Clinical Laboratories | $82.00 | Approved |
| CLM-2026-006927 | 2026-04-10 | Mesa Medical Group | $516.00 | Approved |
| CLM-2026-004853 | 2026-02-28 | Valley Bone and Joint Center | $1,452.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Exact duplicate of an earlier submission.