CLM-2026-006036
Harbor Medical Group, Internal Medicine. Service 2026-02-25 at office (POS 11). Received 2026-04-04.
Member
Resolved through the identity graph
- Member
- James Long
- Member ID
- UHC-80524-88
- Date of birth
- 1972-08-16
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-419417
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-4845
- Coverage period
- 2023-08-01 to present
- Deductible
- $154.91 of $2,500.006%
- Out-of-pocket maximum
- $375.34 of $10,000.004%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 9527891607
- Network
- Out of network
- Rendering NPI
- 4577934852
- Location
- Charlotte, NC · TIN 28-8078153
- Authorisation / referral
- none / REF489655
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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $367.00 | $165.15 | — | — | DeniedCO204 |
| 2 | 93000 | Electrocardiogram with interpretation | — | 1 | 2 | $108.00 | $48.60 | — | — | DeniedCO204 |
| 3 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $58.00 | $26.10 | — | — | DeniedCO204 |
| Totals | $533.00 | $239.85 | — | — | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-392698
- 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-002098 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-25: NAVIGATE-HMO (HMO), effective 2023-08-01. | |
| Timely filing | Pass | Received 38 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 9527891607 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 Medical Group2026-02-25 09:35
Established patient presents with copd, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-04-04 00:40
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-04-04 15:47
Escalated to nurse reviewer for clinical opinion.
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 9527891607 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
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.