CLM-2026-005991
Harbor Primary Care Associates, Family Medicine. Service 2026-01-14 at office (POS 11). Received 2026-02-23.
Member
Resolved through the identity graph
- Member
- Mei Lee
- Member ID
- UHC-02340-97
- Date of birth
- 1978-11-25
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-413846
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-6589
- Coverage period
- 2021-11-01 to present
- Deductible
- $855.42 of $1,000.0086%
- Out-of-pocket maximum
- $1,454.90 of $3,000.0048%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 4898939200
- Network
- Out of network
- Rendering NPI
- 6267636192
- Location
- Austin, TX · TIN 23-1128130
- 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 | $309.00 | $139.05 | — | — | DeniedCO204 |
| 2 | 90471 | Immunization administration | — | 1 | 2 | $27.00 | $12.15 | — | — | DeniedCO204 |
| Totals | $336.00 | $151.20 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. M54.50 Low back pain, unspecified
- 3. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-204761
- 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-010235 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-01-14: NAVIGATE-HMO (HMO), effective 2021-11-01. | |
| Timely filing | Pass | Received 40 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 | Fail | CO204 | Billing provider 4898939200 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Associates2026-01-14 10:22
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-02-23 04:35
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-02-23 17:00
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 4898939200 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024188 | 2026-01-01 | Desert Medical Group | $377.00 | 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
No out-of-network benefit on this plan.