CLM-2026-004928
Harbor Medical Group, Family Medicine. Service 2026-02-15 at office (POS 11). Received 2026-03-07.
Member
Resolved through the identity graph
- Member
- Hiroshi Nichols
- Member ID
- none on golden record
- Date of birth
- 1940-10-19
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-427662
- Relationship
- Self, Denver, CO
Coverage and accumulators
Eligibility
Provider
Billing and rendering
- Billing provider
- Harbor Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 1145537761
- Network
- In network
- Rendering NPI
- 1608327296
- Location
- Phoenix, AZ · TIN 88-8462048
- 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 | 36415 | Venipuncture | — | 1 | 1 | $17.00 | $10.54 | — | — | PendedN30 |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 1,2 | $255.00 | $158.10 | — | — | PendedN30 |
| Totals | $272.00 | $168.64 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- 3. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-427275
- 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-016215 (verified, link confidence 1.00). | |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 20 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 Medical Group (1145537761). | |
| 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 Medical Group2026-02-15 13:23
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-03-07 02:45
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-427275.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Eligibility: No coverage segment found for the member ID on this claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-013261 | 2026-03-01 | Summit Family Practice | $442.00 | Pended |
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
Authorisation must be confirmed with UM before payment.