CLM-2026-000960
Harbor Medical Group, Internal Medicine. Service 2025-12-17 to 2025-12-19 at inpatient hospital (POS 21). Received 2026-01-23.
Member
Resolved through the identity graph
- Member
- Sara Matthews
- Member ID
- UHC-28353-44
- Date of birth
- 1971-11-11
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-413513
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-0893
- Coverage period
- 2025-10-01 to present
- Deductible
- $1,751.80 of $3,500.0050%
- Out-of-pocket maximum
- $4,665.99 of $10,500.0044%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 1814896696
- Network
- In network
- Rendering NPI
- 2561306533
- Location
- San Diego, CA · TIN 46-1297771
- Authorisation / referral
- none / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $187.00 | $102.85 | — | — | PendedIDQ |
| Totals | $187.00 | $102.85 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-570756
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2025-12-17 to 2025-12-20
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-001828; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2025-12-17: - (PPO), effective 2025-10-01. | |
| Timely filing | Pass | Received 35 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 Harbor Medical Group (1814896696). | |
| 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: Harbor Medical Group2025-12-19 14:48
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-570756.pdf7 pages
Itemised statement totalling $187.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-001828; payment withheld until the identity is confirmed.
Other claims for this member
Same resolved identity
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.