CLM-2026-003989
Harbor Primary Care Associates, Family Medicine. Service 2026-02-19 at office (POS 11). Received 2026-03-23.
Member
Resolved through the identity graph
- Member
- Luis Torres
- Member ID
- UHC-13129-49
- Date of birth
- 1984-02-24
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-428240
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-1148
- Coverage period
- 2021-02-01 to present
- Deductible
- $538.01 of $1,000.0054%
- Out-of-pocket maximum
- $496.62 of $2,000.0025%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6148699500
- Network
- In network
- Rendering NPI
- 4077444618
- Location
- Austin, TX · TIN 83-6744178
- 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 | $211.00 | $130.82 | $30.00 | $100.82 | Paid |
| 2 | 36415 | Venipuncture | — | 1 | 2 | $15.00 | $9.30 | $0.00 | $9.30 | Paid |
| 3 | 90471 | Immunization administration | — | 1 | 1 | $28.00 | $17.36 | $0.00 | $17.36 | Paid |
| Totals | $254.00 | $157.48 | $30.00 | $127.48 | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- 3. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-499793
- 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-021622 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-19: MEDICARE-ADV-B (MA), effective 2021-02-01. | |
| Timely filing | Pass | Received 32 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 Primary Care Associates (6148699500). | |
| 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 Primary Care Associates2026-02-19 12:26
Patient seen for hyperlipidemia, unspecified. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-03-23 04:14
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-499793.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
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
Authorisation must be confirmed with UM before payment.