CLM-2026-002162
Harbor Regional Medical Center, Emergency Medicine. Service 2026-03-14 at emergency room (POS 23). Received 2026-03-18.
Member
Resolved through the identity graph
- Member
- Virginia Hawkins
- Member ID
- UHC-96032-88
- Date of birth
- 1945-06-12
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-422168
- Relationship
- Spouse, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5332
- Coverage period
- 2022-08-01 to present
- Deductible
- $1,098.03 of $2,500.0044%
- Out-of-pocket maximum
- $3,111.93 of $10,000.0031%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 9303939968
- Network
- In network
- Rendering NPI
- 9303939968
- Location
- Tempe, AZ · TIN 60-9523328
- Authorisation / referral
- none / REF760123
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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $148.00 | $81.40 | $81.40 | $0.00 | Paid |
| 2 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1,2 | $1,639.00 | $901.45 | $0.00 | $901.45 | Paid |
| Totals | $1,787.00 | $982.85 | $81.40 | $901.45 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. R55 Syncope and collapse
- Patient account
- PA-448878
- 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-020502 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-14: NAVIGATE-HMO (HMO), effective 2022-08-01. | |
| Timely filing | Pass | Received 4 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 Regional Medical Center (9303939968). | |
| 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 Regional Medical Center2026-03-14 18:33
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-448878.pdf9 pages
Itemised statement totalling $1787.00 across 2 lines.
- Er reported_report_PA-448878.pdf6 pages
Emergency department record: triage acuity 2, chief complaint unspecified abdominal pain.
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.