CLM-2026-003053
Harbor Regional Medical Center, Emergency Medicine. Service 2025-12-28 at emergency room (POS 23). Received 2026-01-09.
Member
Resolved through the identity graph
- Member
- Edward Moreno
- Member ID
- UHC-32630-39
- Date of birth
- 1994-11-20
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-407471
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5746
- Coverage period
- 2025-05-01 to present
- Deductible
- $427.99 of $500.0086%
- Out-of-pocket maximum
- $191.88 of $2,000.0010%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 13 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $170.00 | $93.50 | $93.50 | $0.00 | Paid |
| 2 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $153.00 | $84.15 | $0.00 | $84.15 | Paid |
| Totals | $323.00 | $177.65 | $93.50 | $84.15 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-661554
- Frequency code
- 1 (original)
- Accident
- Yes
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-002710 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-12-28: CHOICE-PLUS-PPO (PPO), effective 2025-05-01. | |
| 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 Center2025-12-28 10:48
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-661554.pdf8 pages
Itemised statement totalling $323.00 across 2 lines.
- Er reported_report_PA-661554.pdf5 pages
Emergency department record: triage acuity 4, chief complaint chest pain, unspecified.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean 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.