CLM-2026-003166
Harbor Regional Medical Center, Emergency Medicine. Service 2026-03-15 at emergency room (POS 23). Received 2026-04-19.
Member
Resolved through the identity graph
- Member
- Debra Warren
- Member ID
- UHC-72923-64
- Date of birth
- 1972-08-21
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-420686
- Relationship
- Spouse, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-9198
- Coverage period
- 2022-08-01 to present
- Deductible
- $1,761.16 of $3,500.0050%
- Out-of-pocket maximum
- $6,919.15 of $14,000.0049%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 22 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 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $760.00 | $418.00 | — | — | PendedIDQ |
| 2 | 99284 rev 0450 | Emergency department visit, high severity | 25 | 1 | 1 | $1,127.00 | $619.85 | — | — | PendedIDQ |
| Totals | $1,887.00 | $1,037.85 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-412478
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
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-003143; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-03-15: SELECT-EPO (EPO), effective 2022-08-01. | |
| 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 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 Center2026-03-15 16:14
Patient seen for unspecified abdominal pain.
Attachments
Documents received with the claim
- Itemized billitemized_PA-412478.pdf9 pages
Itemised statement totalling $1887.00 across 2 lines.
- Er reported_report_PA-412478.pdf6 pages
Emergency department record: triage acuity 3, chief complaint unspecified abdominal pain.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-003143; 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.