CLM-2026-005540
Harbor Medical Group, Family Medicine. Service 2026-08-05 at office (POS 11). Received 2026-09-25.
Member
Resolved through the identity graph
- Member
- Arjun Larson
- Member ID
- UHC-89929-24
- Date of birth
- 1991-01-24
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-410376
- Relationship
- Spouse, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1954
- Coverage period
- 2025-08-01 to present
- Deductible
- $510.16 of $2,500.0020%
- Out-of-pocket maximum
- $425.42 of $10,000.004%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 1145537761
- Network
- In network
- Rendering NPI
- 4249207661
- 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 | $12.00 | $7.44 | — | — | DeniedCO18 |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 2 | $182.00 | $112.84 | — | — | DeniedCO18 |
| Totals | $194.00 | $120.28 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-623849
- 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-027261 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-05: CHOICE-PLUS-PPO (PPO), effective 2025-08-01. | |
| Timely filing | Pass | Received 51 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-005539: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| 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 Group2026-08-05 15:44
Patient seen for type 2 diabetes mellitus without complications.
- SystemSystem: Claims system2026-09-25 04:20
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-005539: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023959 | 2026-08-21 | Northgate Medical Group | $309.00 | Approved |
| CLM-2026-005539 | 2026-08-05 | Harbor Medical Group | $194.00 | Approved |
| CLM-2026-024302 | 2026-07-11 | Summit Regional Medical Center | $213.00 | Approved |
| CLM-2026-025790 | 2026-04-02 | Cornerstone Diabetes Center | $296.00 | Approved |
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
Exact duplicate of an earlier submission.