CLM-2026-005337
Harbor Diagnostic Imaging, Radiology. Service 2026-08-07 at outpatient hospital (POS 22). Received 2026-08-17.
Member
Resolved through the identity graph
- Member
- Carl Gardner
- Member ID
- UHC-45737-62
- Date of birth
- 2004-02-12
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-427586
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-0128
- Coverage period
- 2025-01-01 to present
- Deductible
- $11.57 of $1,000.001%
- Out-of-pocket maximum
- $711.98 of $2,000.0036%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 1623659319
- Network
- In network
- Rendering NPI
- 1623659319
- Location
- Houston, TX · TIN 54-3766877
- Authorisation / referral
- none / REF844323
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 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $549.00 | $301.95 | — | — | Review |
| Totals | $549.00 | $301.95 | — | — | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- Patient account
- PA-906231
- 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 | Pass | Attached to MBR-040677 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-07: NAVIGATE-HMO (HMO), effective 2025-01-01. | |
| Timely filing | Pass | Received 10 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 Diagnostic Imaging (1623659319). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Patient seen for headache, unspecified. Note dictated; signature pending.”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Harbor Diagnostic Imaging2026-08-07 13:09
Patient seen for headache, unspecified. Note dictated; signature pending.
- SystemSystem: Claims system2026-08-17 06:44
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
- Itemized billitemized_PA-906231.pdf7 pages
Itemised statement totalling $549.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Patient seen for headache, unspecified. Note dictated; signature pending.”.
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
Development letter outstanding.