Institutional claim · UB-04 · EDI 837I
CLM-2026-001897
Harbor Medical Group, Internal Medicine. Service 2026-08-14 to 2026-08-17 at inpatient hospital (POS 21). Received 2026-09-05.
DeniedOut of network
Billed
$507.00
2 lines
Allowed
$228.15
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Janice Sto
- Member ID
- UHC-96551-62
- Date of birth
- 1955-05-28
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-428304
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-0189
- Coverage period
- 2025-08-01 to 2026-07-03
- Deductible
- $309.68 of $1,000.0031%
- Out-of-pocket maximum
- $850.26 of $4,000.0021%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 9527891607
- Network
- Out of network
- Rendering NPI
- 8111230917
- Location
- Charlotte, NC · TIN 28-8078153
- 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 | 59 | 1 | 1 | $204.00 | $91.80 | — | — | DeniedCO27 |
| 2 | 99215 | Office visit, established patient, high complexity | 59 | 1 | 1,2 | $303.00 | $136.35 | — | — | DeniedCO27 |
| Totals | $507.00 | $228.15 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. I10 Essential (primary) hypertension
Claim header
- Patient account
- PA-379979
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-08-14 to 2026-08-18
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-012615 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-14 is after coverage terminated on 2026-07-03. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 19 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Harbor Medical Group2026-08-17 10:26
Patient seen for unspecified atrial fibrillation.
- SystemSystem: Claims system2026-09-05 06:33
Attachments
Documents received with the claim
- Itemized billitemized_PA-379979.pdf7 pages
Itemised statement totalling $507.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-14 is after coverage terminated on 2026-07-03. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. Bundling (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
No other claims.
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Denied by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
DeniedCO27scenario: Coverage terminated
Service after coverage termination.