CLM-2026-006057
Harbor Medical Group, Internal Medicine. Service 2026-04-11 at office (POS 11). Received 2026-04-24.
Member
Resolved through the identity graph
- Member
- Zachary Hunt
- Member ID
- none on golden record
- Date of birth
- 1990-01-21
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-426003
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- NAVIGATE-HMO HMO group GRP-5158
- Coverage period
- 2025-08-01 to present
- Deductible
- $284.93 of $500.0057%
- Out-of-pocket maximum
- $36.84 of $2,000.002%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 1814896696
- Network
- In network
- Rendering NPI
- 7768527336
- Location
- San Diego, CA · TIN 46-1297771
- Authorisation / referral
- none / REF135459
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 | $308.00 | $190.96 | — | — | PendedIDQ |
| Totals | $308.00 | $190.96 | — | — | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-864087
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-000129; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-04-11: NAVIGATE-HMO (HMO), effective 2025-08-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 13 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 Medical Group (1814896696). | |
| 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 Group2026-04-11 09:47
Follow-up for copd, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-000129; payment withheld until the identity is confirmed. Eligibility: Active on 2026-04-11: NAVIGATE-HMO (HMO), effective 2025-08-01. Coverage found by name and date of birth because the claim carried no usable member ID.
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
Clean claim, priced at contract rate.