CLM-2026-033886
Heritage Primary Care Associates, Family Medicine. Service 2026-03-13 at office (POS 11). Received 2026-03-21.
Member
Resolved through the identity graph
- Member
- Kimberly Sullivan
- Member ID
- none on golden record
- Date of birth
- 1957-07-08
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-411114
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Eligibility
Provider
Billing and rendering
- Billing provider
- Heritage Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 8400209101
- Network
- In network
- Rendering NPI
- 4598007118
- Location
- San Diego, CA · TIN 62-9200818
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $186.00 | $115.32 | — | — | PendedN30 |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $303.00 | $187.86 | — | — | PendedN30 |
| Totals | $489.00 | $303.18 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- 3. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-301081
- 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-021183 (verified, link confidence 1.00). | |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| 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 Primary Care Associates (8400209101). | |
| 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 Associates2026-03-13 09:06
Follow-up for acute upper respiratory infection, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Eligibility: No coverage segment found for the member ID on this claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004964 | 2026-03-08 | Cornerstone Clinical Laboratories | $58.00 | Pended |
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
Clean claim, priced at contract rate.