CLM-2026-033250
Heritage Primary Care Associates, Family Medicine. Service 2026-03-22 at office (POS 11). Received 2026-05-06.
Member
Resolved through the identity graph
- Member
- Mariana Herrera
- Member ID
- UHC-47508-09
- Date of birth
- 1979-09-25
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-410471
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-6363
- Coverage period
- 2022-05-01 to present
- Deductible
- $420.42 of $2,500.0017%
- Out-of-pocket maximum
- $1,729.60 of $5,000.0035%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 3703132464
- Network
- In network
- Rendering NPI
- 1402295996
- Location
- Tempe, AZ · TIN 64-9033821
- 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 | $39.00 | $24.18 | $24.18 | $0.00 | Paid |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 2 | $220.00 | $136.40 | $0.00 | $136.40 | Paid |
| Totals | $259.00 | $160.58 | $24.18 | $136.40 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-359635
- 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-013480 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-22: OPTIONS-PPO (PPO), effective 2022-05-01. | |
| Timely filing | Pass | Received 45 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 (3703132464). | |
| 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 Associates2026-03-22 13:46
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.