CLM-2026-002578
Harbor Regional Medical Center, Emergency Medicine. Service 2026-08-27 at emergency room (POS 23). Received 2026-09-08.
Member
Resolved through the identity graph
- Member
- Jordan Ellis
- Member ID
- UHC-92342-99
- Date of birth
- 2004-09-04
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-415082
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-5205
- Coverage period
- 2023-11-01 to present
- Deductible
- $692.43 of $1,000.0069%
- Out-of-pocket maximum
- $210.62 of $4,000.005%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 4 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 / 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 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $162.00 | $89.10 | $89.10 | $0.00 | Paid |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1,2 | $944.00 | $519.20 | $0.00 | $519.20 | Paid |
| Totals | $1,106.00 | $608.30 | $89.10 | $519.20 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. R55 Syncope and collapse
- Patient account
- PA-867943
- 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-006017 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-08-27: MEDICARE-ADV-A (MA), effective 2023-11-01. | |
| Timely filing | Pass | Received 12 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 Center2026-08-27 17:43
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-867943.pdf6 pages
Itemised statement totalling $1106.00 across 2 lines.
- Er reported_report_PA-867943.pdf3 pages
Emergency department record: triage acuity 3, 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002579 | 2026-08-27 | Harbor Regional Medical Center | $1,106.00 | Needs review |
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.