Claims workbench/CLM-2026-005969
Professional claim · CMS-1500 · Provider portal

CLM-2026-005969

Harbor Medical Group, Internal Medicine. Service 2026-03-06 at office (POS 11). Received 2026-04-14.

ApprovedOut of network
Billed
$64.00
1 line
Allowed
$28.80
contract rate applied
Plan pays
$3.80
approved
Member owes
$25.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Joyce Tran
Member ID
UHC-45030-13
Date of birth
1939-04-24
Identity
Verified4 records, confidence 0.99
Claim record
CLMCLM-414538
Relationship
Self, Miami, FL

Coverage and accumulators

Found by member ID

Plan
OPTIONS-PPO PPO group GRP-2908
Coverage period
2021-09-01 to present
Deductible
$1,094.47 of $2,500.0044%
Out-of-pocket maximum
$370.26 of $10,000.004%
Copays
office $25.00, specialist $40.00, emergency $350.00
Physical therapy visits
18 of 20 used

Provider

Billing and rendering

Billing provider
Harbor Medical Group
Internal Medicine · taxonomy 207R00000X
NPI
9527891607
Network
Out of network
Rendering NPI
7399724120
Location
Charlotte, NC · TIN 28-8078153
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
180053Comprehensive metabolic panel—11$64.00$28.80$25.00$3.80Paid
Totals$64.00$28.80$25.00$3.80
Diagnoses (ICD-10-CM)
  • 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
Claim header
Patient account
PA-690877
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

CheckResultCodeDetail
Member identityPassAttached to MBR-022891 (verified, link confidence 0.99).
EligibilityPassActive on 2026-03-06: OPTIONS-PPO (PPO), effective 2021-09-01.
Timely filingPassReceived 39 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkNoteOut-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Harbor Medical Group2026-03-06 10:27

    Established patient presents with chronic kidney disease, stage 3 unspecified; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Explanation of benefits

What the member will see

Amount billed
$64.00
Plan discount
$35.20
out-of-network allowance
Plan paid
$3.80
You may owe
$25.00
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-21 13:43
    Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

Clean claim: the rules engine approved it, so no AI review was needed.

Examiner decision

Approved by Claims rules engine; an examiner may still override

Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queueMember identity