CLM-2026-003265
Harbor Diabetes Center, Endocrinology. Service 2025-08-19 at office (POS 11). Received 2026-02-12.
Member
Resolved through the identity graph
- Member
- Jean Griffn
- Member ID
- UHC-83368-23
- Date of birth
- 2005-09-12
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-411323
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- - PPO group N/A
- Coverage period
- 2022-09-01 to present
- Deductible
- $1,562.56 of $2,500.0063%
- Out-of-pocket maximum
- $3,230.03 of $10,000.0032%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Diabetes CenterEndocrinology · taxonomy 207RE0101X
- NPI
- 7519485602
- Network
- In network
- Rendering NPI
- 1941090437
- Location
- Tempe, AZ · TIN 55-9687647
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $237.00 | $146.94 | — | — | DeniedCO29 |
| Totals | $237.00 | $146.94 | — | — | ||||||
- 1. E03.9 Hypothyroidism, unspecifiedprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-639944
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-012567 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-08-19: - (PPO), effective 2022-09-01. | |
| Timely filing | Fail | CO29 | Received 177 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Diabetes Center (7519485602). | |
| 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 Diabetes Center2025-08-19 15:28
Patient seen for hypothyroidism, unspecified.
- SystemSystem: Claims system2026-02-12 03:49
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-02-12 14:39
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 177 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Received after the timely-filing limit.