CLM-2026-003258
Harbor Regional Medical Center, Emergency Medicine. Service 2026-04-16 at emergency room (POS 23). Received 2026-05-13.
Member
Resolved through the identity graph
- Member
- Anthony Kelly
- Member ID
- UHC-84357-74
- Date of birth
- 2000-12-23
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-400682
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-4330
- Coverage period
- 2023-02-01 to present
- Deductible
- $587.47 of $1,000.0059%
- Out-of-pocket maximum
- $623.77 of $3,000.0021%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 12 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 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $2,722.00 | $1,497.10 | $250.00 | $1,247.10 | Paid |
| 2 | 96374 rev 0260 | IV push, single drug | — | 1 | 2 | $253.00 | $139.15 | $0.00 | $139.15 | Paid |
| 3 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,275.00 | $701.25 | $0.00 | $701.25 | Paid |
| Totals | $4,250.00 | $2,337.50 | $250.00 | $2,087.50 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- Patient account
- PA-331241
- Frequency code
- 1 (original)
- Accident
- No
- 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-003081 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-04-16: CORE-HMO (HMO), effective 2023-02-01. | |
| Timely filing | Pass | Received 27 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 Center2026-04-16 17:08
Follow-up for pneumonia, unspecified organism. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-331241.pdf6 pages
Itemised statement totalling $4250.00 across 3 lines.
- Er reported_report_PA-331241.pdf6 pages
Emergency department record: triage acuity 3, chief complaint pneumonia, unspecified organism.
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032352 | 2026-07-11 | Desert Medical Group | $219.00 | Approved |
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.